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Complaint Investigation

Charlotte Bay Rehab And Care Center

March 22, 2025 · Port Charlotte, FL · 4033 Beaver Lane
Citations 3
CMS Rating 1/5
Beds 164
Provider ID 105363
Healthcare Facility
Charlotte Bay Rehab And Care Center
Port Charlotte, FL  ·  View full profile →
Inspection Summary

CHARLOTTE BAY REHAB AND CARE CENTER in PORT CHARLOTTE, FL — inspection on March 22, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF600
Immediate Few vital signs are obtained daily. affected

F-F600 Free from Abuse and Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin with indicators of Neglect including screening, training, prevention, identification, investigation, protection, and reporting.

On 3/19/25 the facility began staff education on Abuse and Neglect with the emphasis on failure to protect resident rights to be free of neglect by failing to monitor urinary output and to monitor the resident when the catheter was discontinued. 141/171 staff members have received this education by 3/21/25.

All remaining staff will receive this education prior to returning to work.

105363

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105363 B.

Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

Review of the Administrator's job description signed on 1/30/24 revealed, The primary purpose of this position is to direct the day-t0-day functions of the facility in accordance with current federal state and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times.

The duties and responsibilities of the Administrator included, Ensure that an adequate number of appropriately trained, competent, licensed professionals and non-licensed personnel are on duty at all times to meet the needs of the residents.

105363

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105363 B.

Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

Summary of all corrective actions taken: Nursing staff education has been initiated r/t (related to) neglect with an emphasis on foley catheter care upon receiving this allegation .

Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] from an acute care hospital.

Diagnoses included prostatic hyperplasia (enlarged prostate) with urinary symptoms. Resident #1 was admitted with an indwelling urinary catheter (catheter inserted in the bladder to drain urine).

Review of the Treatment Administration Record (TAR) for January 2025 revealed on 1/28/25 Licensed Practical Nurse (LPN) staff B changed Resident #1's urinary catheter.

The clinical record lacked documentation LPN Staff B verified the catheter was properly inserted and draining urine.

On 3/18/25 at 10:00 a.m., in a telephone interview LPN Staff B said she followed the physician's order to change Resident #1's catheter. On 1/28/25 at approximately 5:30 a.m., when she changed the catheter, there was no urine in the drainage bag.

She said she got a small amount of urine return when she inserted the catheter and had no blood.

She verified she left work on 1/28/25 at 7:00 a.m., Resident #1 had no urine in the drainage bag.

She did not write a progress note for the catheter change, including the small amount of urine return.

105363

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105363 B.

Wing 03/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PORT CHARLOTTE, FL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CHARLOTTE BAY REHAB AND CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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