Port Charlotte Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Port Charlotte Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835May 8, 2026

  Based on observations, clinical record review, review of facility's policies and procedures and staff interviews, the facility administration failed to provide effective oversight to ensure ongoing implementation of a water management program to reduce the risk of growth and spread of Legionella (water-borne disease causing bacteria), and failed to minimize the risk of ongoing exposure to Legionella for 145 residents from potentially contaminated water sources, in response to a resident's confirmed diagnosis of Legionnaires' Disease (potentially fatal form of pneumonia caused by Legionella bacteria) that may have been acquired at the facility.The findings included:Refer to F880Review of the facility provided list of Key Facility Staff revealed:The Administrator's date of hire was… […]

• Immediate jeopardy, widespreadF880May 8, 2026

  Based on observations, clinical record review, review of facility's policies and procedures, and interviews, the facility failed to establish and implement a water management program to mitigate the risk of Legionella (waterborne disease-causing bacteria) exposure. The facility failed to minimize the risk of ongoing exposure to Legionella from potentially contaminated water sources in response to a resident's confirmed diagnosis of Legionnaire's disease (potentially fatal form of pneumonia caused by Legionella bacteria) that may have been acquired at the facility.The findings included:Refer to F835Review of the facility's Water Management Program (WMP) revealed, Legionnaires' disease is a serious type of pneumonia caused by bacteria called Legionella which live in water. […]

• Actual harm, isolatedF689May 8, 2025

  Based on observations, record review, resident and staff interviews, the facility failed to implement appropriate interventions, including adequate supervision to prevent falls for 2 (Residents #1 and #4) of 4 residents reviewed with multiple falls and/or fall related injuries. The findings included: 1. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included but were not limited to generalized muscle weakness, difficulty in walking, lack of coordination, repeated falls, abnormalities of gait and mobility, severe dementia with other behavioral disturbances. Review of the Annual Minimum Data Set (MDS) assessment with a target date of 9/9/24 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 03. […]

• No harm, potential for more than minimal, widespreadF812Dec 19, 2024

  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). […]

• No harm, potential for more than minimal, patternF700Sep 30, 2021

  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. […]