Port Charlotte Rehabilitation Center

Based on observation, record review and staff interviews, the facility failed to ensure 1 (Dietary aide Staff N) of 1 staff observed operating the dishwasher was trained, and competent to test the sanitizing solution of the low temp dishwasher to ensure dishes were properly sanitized to prevent foodborne illnesses of residents consuming an oral diet. The findings included: The facility Dish Machine Overview purpose states to maintain proper use and function of dish machine. Number 6 states Perform chemical test strip procedure following the last cycle. Confirm the test strip color matches the manufacturers' recommendation of PPM (parts per million). If not, run dishes through machine again ensuring proper PPM met. On 12/16/24 at 9:15 a.m., the Initial kitchen tour was conducted with the Kitchen Manager. Dietary Aide Staff N was observed operating the dishwasher. The Kitchen Manager said the dishwasher was a low temp machine and required the use of a sanitizing agent. Staff N was unable to use a test strip to measure the concentration of the sanitizer. Using a translator, Staff N…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility's policy and procedure, resident and staff interview, the facility failed to accommodate the needs of 1 (Resident #59) of 4 dependent residents reviewed by failing to place the call system within reach of the resident. The findings included: The Facility policy Universal Fall Precautions purpose said Universal fall precautions revolve around keeping the patient's environment safe and comfortable. This included maintain call light within reach. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 11/25/24 revealed Resident #59's cognition was intact with a Brief Interview for Mental Status score of 13. The assessment noted the resident was dependent for wheelchair mobility. On 12/16/24 at 1:30 p.m., Resident #59 was observed sitting in a wheelchair in her room. The call light was wrapped around the side rail of the bed behind the wheelchair, and not within the resident's reach. Photographic evidence obtained. In an interview during the observation, Resident #59 said she was not allowed to get up and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to revise the comprehensive care plans with resident centered interventions to ensure 1 (Resident #85 ) of 3 sampled residents reviewed achieved their highest practicable physical, mental and psychosocial wellbeing. The findings included: Review of the medical record for Resident #85 revealed an original admission date of 10/3/24 and readmissions on 10/16/24 and 11/13/24. Diagnoses included atrial fibrillation and chronic heart failure. Review of the hospital record for 10/11/24, Resident #85 had a cardiac pacemaker. Review of the admission nursing evaluations dated 10/16/24 and 11/13/24 revealed documentation Resident #85 had a cardiac pacemaker. Review of Resident #85's care plans revealed there no care plan addressing the cardiac pacemaker. On 12/18/24 at 9:10 a.m., Resident #85 was observed in his room with family members visiting. In an interview the resident's daughter said her father had not seen the cardiologist for the past two years for a pacemaker check. She said she visits her father every day and no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, resident and family interviews and review of facility policy and procedures the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #5, and #24) of 3 residents reviewed for activities of daily living (ADL's). The findings included: The facility policy Activities of Daily Living, Supporting documented Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including hygiene (bathing, dressing, grooming and oral care. 1. Review of the clinical record revealed Resident #5 was [AGE] years old with an admission date of 10/17/24 and diagnoses including fracture of lower end of right femur, muscle weakness, and need for assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, resident and family interviews and review of facility policy and procedures the facility failed to provide the necessary care and services to maintain continence for 1(Resident #5) and failed to maintain indwelling urinary catheters in a safe and sanitary manner for 2 (Resident #134 and #85) of 3 residents reviewed for bowel and bladder incontinence and urinary catheters. The findings included: The facility policy Activities of Daily Living, Supporting documented Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including elimination (toileting). 1. Review of the clinical record revealed Resident #5 was [AGE] years old with an admission date of 10/17/24 and diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and resident and staff interview, the facility failed to store CPAP (continuous positive airway pressure) equipment in a sanitary manner for 3 (Resident #10, #70 and #14) of 3 resident's reviewed for respiratory care and sleep apnea. This had the potential to cause respiratory infections in compromised residents. The findings included: 1. During observations on 12/16/24 at 1:16 p.m., and 12/17/24 at 4:41 p.m., Resident #10 was noted with a CPAP machine and the mask that was uncovered and lying on top of the nightstand. Photographic evidence obtained. Review of Resident #10's clinical record revealed there was no physician order and no care instructions for the use of the CPAP machine. 2. On 12/16/24 at 1:10 p.m., Resident #70 was observed with a CPAP machine in her room on the bedside table. The mask was uncovered and lying on the table next a cup of liquid and the machine had food and personal items stored next to it. The resident said the staff take care of the CPAP machine for her.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, resident records review and facility policy review the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflects resident's oral status to identify dental care needs for 1 (Resident #123) of 3 residents reviewed for accuracy of assessment. The findings included: The Resident Assessment Instrument Manual (RAI version 3.0) noted the steps for assessment for dental status included, Conduct exam of the resident's lips and oral cavity with dentures or partials removed if applicable. Use a light source that is adequate to visualize the back of the mouth. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. Review of the clinical record for Resident #123 revealed an admission date of 3/29/22. The admission MDS with an assessment reference date of 4/7/22 noted the resident had, obvious or likely cavity or broken natural teeth. Review of dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, review of facility guidelines manual, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1 (Resident #121) of 27 residents reviewed for activities of daily living (ADLs). The findings included: The facility Clinical/Rehabilitation Guidelines Manual, ADL Care, specified: Proper ADL care is vital to all residents within our center. To ensure that the process and expectations of ADL care are clear, consistently assessed in order to maintain compliance. Review of the clinical record revealed Resident #121 had an admission date of 2/9/23 with diagnoses including cerebral infarction with left hemiparesis (weakness), blind in right eye and muscle weakness. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/16/23 documented Resident #121 required extensive assistance of one person for personal hygiene and required the assistance of two for bathing. The MDS noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for 1 (Resident #144) of 2 sampled residents receiving intravenous medications. The findings included: The facility policy for Catheter Insertion and Care (Midline Dressing Changes) noted Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. General Guidelines included changing the midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact or compromised in any way. Review of the clinical record for Resident #144 revealed an admission date to the facility of 4/27/23. The resident was transferred to the hospital on 5/9/23, returned to the facility on 5/12/23. On 5/14/23 Resident #144 was transferred to an acute care hospital with return anticipated. On 5/16/23 Resident #144 returned to the facility. Review of the Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to implement individualized care planned interventions to address the behavioral health needs of 1 (Resident #135) of 2 residents reviewed for behavioral health. The findings included: Review of the clinical record revealed Resident #135 had an admission date to the facility of 11/22/22. The admission Minimum Data Set (MDS) assessment with an assessment reference date of 11/28/22 listed diagnoses including depression, and dementia. The resident's cognition was moderately impaired as indicated by a Brief Interview for Mental Status of 11. Resident #135 was able to be interviewed. The resident indicated it was very important for her to have books, newspapers, magazines to read, listen to music she likes, keep up with the news, do things with groups of people, go outside, and get fresh air when the weather is good, participate in religious services or practices. The assessment noted it was very important for the resident to do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of facility policy and procedure, resident and staff interviews, the facility failed to ensure 1(Resident #62) of 5 residents reviewed for medication administration received the physician ordered intravenous antibiotic without unnecessary interruption to treat an infection in a surgical wound. The findings included: The facility policy Medication Administration General Guidelines (revised 8/2014) documented, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of scheduled time . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility . Review of the clinical record revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, resident and staff interviews the facility failed to provide timely assistance with referrals for outside oral surgery services to meet the needs of 1(Resident #123) of 3 residents reviewed for dental services. The findings included: Review of facility policy titled Social Services release date 11/15/2005 which states, General services, which social service department may assist, oversee, or manage, could include . Making referrals for and obtaining services from outside resource. Review of the progress notes in the clinical record for Resident #123 revealed: On 8/18/22 a dental progress note documented fracture of tooth #29 and severe nonrestorative decay with recommended extraction on teeth #2, 3, 8, 9, and 10. On 1/31/23 a dental progress note documented fractured teeth including #3, 7, 8, 9, 10, with recommendation to extract teeth #2, 3, 7, 8, 9, 10, and 20. A dental specialist referral form dated 3/10/23 documented recommended extraction of teeth #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 15. The referral noted to call the dental insurance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, policy review, staff, resident, and family interviews, the facility failed to ensure 7 (Resident #261, #31, #63, #49, #67, #257, and #8) of 10 residents reviewed for accidents were assessed for alternative interventions prior to the use of bed rails or if an alternative was identified, why the alternative failed to meet the resident's need. In addition, the facility failed to have ongoing routine maintenance of the bed rails in accordance with manufacturer's recommendations. The findings included: The facility's Safe and Effective Use of Bed Rails policy dated 2018 indicated, To prevent entrapment and other safety hazards associated with bed rail use, the facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a side or bed rail is used, the facility must ensure correct installation, use and maintenance of bed rails, including but not limited to the following: assess the resident for risk of entrapment from the bed rails prior to installation. 1. On 9/27/21 at 12:23 p.m., Resident #31's bed was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident and staff interviews, record review, and review of facility policies and procedures, the facility failed to provide the necessary care and services to maintain grooming and hygiene for 3 (Resident #17, #63, and #101) of 3 dependent residents reviewed for assistance with activities of daily living. This has the potential to cause psychological harm to the resident. The findings included: A review of the facility policy, CCHC 0608 Fingernail Care specified, Purpose. To promote circulation to the hands. To clean fingernails. 1. A review of Resident #63' s clinical record revealed a care plan specifying Resident #63 had an Activities of Daily Living (ADLs) self-care performance deficit. The Significant Change Minimum Data Set with a date of 8/26/21 documented Resident #63 required extensive assistance of one person with hygiene. Resident #63 had diagnoses including dementia with behavioral disturbance. On 9/27/21 at 11:03 a.m., Resident #63's fingernails were observed extending over 1/2 inch from the tip with a large amount of brown substance under the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.