Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Port Charlotte Rehabilitation Center during CMS and state inspections, most recent first.
Failure to oversee water management program and respond to Legionella exposure: The Administrator, DON/IP, and Maintenance Director did not ensure effective oversight of the facility’s water system after a resident was diagnosed with Legionnaires’ Disease and was believed to have been symptomatic during the stay. The facility had non-operational mixing valves, non-functional water heater gauges, an unplugged circulation pump, and water temperatures below the stated target range, while requested water system risk assessment and monitoring records were not provided. The facility also delayed committee action and did not fully implement DOH guidance related to hot water temperature, flushing, and showerhead positioning; later environmental samples from the resident’s room and another room were positive for Legionella pneumophila.
Failure to implement WMP for Legionella exposure. The facility had a written WMP, but it did not show ongoing monitoring of the water system or documentation that the program was effective. A resident with pneumonia and acute resp failure later had confirmed Legionella, and the DOH said the resident was in the facility for the entire incubation period. Surveyors found non-operational mixing valves, non-functional water heater gauges, an unplugged circulation pump, and water temps below the stated control level; the DON, Administrator, and Maintenance Director did not initiate special precautions or further action when notified.
Two residents with cognitive impairment and a history of multiple falls were not provided with consistent supervision or appropriate interventions to prevent accidents. One resident, who was agitated and self-propelling in a wheelchair without footrests, sustained serious injuries after a fall during transport. Another resident, dependent on staff for mobility, experienced repeated falls, sometimes without required fall mats in place, and was found on the floor multiple times. Care plans were not consistently updated or followed, and staff did not always provide the necessary supervision or document interventions.
A dietary aide was observed operating a low-temp dishwasher without being trained to test the sanitizing solution, leading to potential foodborne illness risks. The aide had been documenting sanitizer tests without understanding the process, and the Kitchen Manager was unaware of the aide's training status.
A resident in a wheelchair with intact cognition was unable to reach the call light, which was consistently placed out of reach, contrary to the facility's policy on Universal Fall Precautions. Despite the resident's ability to use the call light, it was not consistently accessible, leading to a deficiency. Staff acknowledged the oversight, and administration confirmed the call light should be within reach unless the resident is unable to use it.
A facility failed to revise the care plan for a resident with a cardiac pacemaker, despite documentation of the device in medical records. The resident's daughter reported no cardiologist visits for two years, and staff confirmed the absence of a care plan and cardiology consult order. The DON acknowledged the need for a care plan.
Two residents in an LTC facility did not receive scheduled showers, despite requiring substantial assistance due to fractures and mobility issues. Resident #5 did not receive a shower since admission, only bed baths, until December. Resident #24 also did not receive any showers since November admission, only bed baths. Staff interviews revealed inconsistencies in following the shower schedule and documentation, leading to deficiencies in personal hygiene care.
A resident was not on a toileting program despite being incontinent, leading to discomfort and potential health risks. Two residents with indwelling urinary catheters received improper care, with drainage bags improperly placed, posing risks of injury and infection. Staff interviews and observations confirmed these deficiencies.
The facility failed to store CPAP equipment properly for three residents, risking respiratory infections. Observations revealed uncovered CPAP masks and machines without physician orders or care instructions. The DON was unaware of the lack of orders and stated that equipment should be stored in plastic bags when not in use.
Failure to oversee water management program and respond to Legionella exposure
Penalty
Summary
The facility administration failed to provide effective oversight to ensure ongoing implementation of its water management program after a resident was diagnosed with Legionnaires’ Disease and was believed by the Department of Health to have been symptomatic while staying at the facility for the entire incubation period. The Administrator, DON/Infection Preventionist, and Maintenance Director were identified as key staff responsible for operations, infection prevention, and maintenance, and the facility’s own Water Management Program assigned responsibility to a committee including the Administrator, DON, Medical Director, and Maintenance Supervisor. The report states that the DON did not oversee the water management program as part of infection prevention and did not initiate preventive measures when notified of the diagnosis, and the Administrator did not implement the interventions listed in the facility’s Water Management Plan when informed of the diagnosis. The facility’s water system had multiple deficiencies identified during the survey. The facility had 3 mixing valves for 7 water heaters, and all 3 mixing valves were non-operational. Five of the 7 water heater temperature gauges were non-functional. The circulation pump on the Tarpon Unit was unplugged, and water temperatures in the tanks ranged from 114 degrees F to 117 degrees F. The Maintenance Director stated that the mixing valves had been non-operational since he began working at the facility 6 years earlier and that no attempts had been made during that time to repair them. Documentation of a water system risk assessment and monitoring such as visual inspection, temperature checks, and disinfectant checks was requested but not provided. The facility also did not promptly implement the Department of Health’s recommendations after being notified of the possible Legionella exposure. The DOH informed the facility that the resident became symptomatic while staying there and that environmental conditions could support Legionella growth in the plumbing. The DOH recommended professional consultation, maintaining domestic hot water at a minimum of 140 degrees F, flushing shower and sink faucets, and allowing showerheads to hang to fully drip out. The facility’s Safety Committee did not meet until 14 days after the diagnosis notification, and the Performance Improvement Plan did not include all of the DOH recommendations. The room occupied by the resident had a showerhead tucked between the wall and handrail rather than hanging to drip out, and later environmental testing from the resident’s room and another room was positive for Legionella pneumophila.
Failure to Implement Water Management Program for Legionella
Penalty
Summary
The facility failed to establish and implement an infection prevention and control program that included an effective water management program to reduce the risk of Legionella exposure. The facility’s written Water Management Program described a committee structure, risk assessment, monitoring of water temperatures and disinfectant levels, corrective actions when control limits were not met, and documentation of testing and committee activity. However, when the issue arose, the facility did not have documentation showing that the water system was being monitored in the areas identified in the plan, and the only testing documentation provided was negative Legionella results from a limited set of samples collected the prior year from the ice machine, water dispensers, and fountain. Resident #1 was admitted with diagnoses including pneumonia of unspecified organism and acute respiratory failure with hypoxia. The resident later developed respiratory distress and was transferred emergently to an acute care hospital because oxygen saturation could not be maintained above 88% without oxygen. The Department of Health notified the facility that the resident had a confirmed Legionella infection and that the resident had been in the facility during the entire incubation period. The facility’s DON acknowledged receiving the notification and said she informed the Administrator and Maintenance Director, but she was not aware of an investigation or testing being done to address the concern. During the survey, the facility was found to have three mixing valves serving seven water heaters, and all three mixing valves were non-operational. Five of the seven water heater temperature gauges were non-functional, the circulation pump for one unit was unplugged, and water temperatures in the tanks were measured between 114 degrees F and 117 degrees F. The Maintenance Director stated the mixing valves had been non-operational for six years. The Administrator stated the facility was waiting for direction from the Department of Health and had not started implementing the recommendations because they were viewed as ideas rather than requirements. The DON and Regional Director of Clinical Services also stated they believed the resident had Legionella before admission, and no special precautions had been initiated for current residents to prevent exposure from possible contaminated water. The facility also could not provide documentation of a completed risk assessment showing where hazardous conditions could occur or documentation that the Water Management Program was being run as designed and was effective.
Failure to Implement Adequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement appropriate interventions and provide adequate supervision to prevent falls for two residents with a history of multiple falls and fall-related injuries. One resident, with severe dementia, generalized muscle weakness, and repeated falls, experienced several incidents where she was found on the floor, including a witnessed fall resulting in a nasal and rib fracture. During this incident, the resident was being transported in a wheelchair without footrests, as requested by her son, and her feet became entangled, leading to the fall. The care plan did not address the absence of footrests, and there was no documentation of interventions for safe transport. The resident also had episodes of agitation and purposely sliding out of her chair, but the care plan lacked interventions for increased supervision during these behaviors. Another resident, with moderate cognitive impairment, debility, and a history of falls, was dependent on staff for mobility and had multiple falls within a short period. Despite being identified as a high fall risk and having care plan interventions such as fall mats and a scoop mattress, the resident was repeatedly found on the floor, sometimes without the prescribed fall mats in place. The resident was unable to consistently use the call light and often attempted to get out of bed or walk unassisted, resulting in injuries such as skin tears and bruising. Observations revealed inconsistencies in the implementation of care plan interventions, such as the absence of fall mats when required. Staff interviews and record reviews indicated that supervision was not consistently provided, and care plan interventions were not always updated or followed according to the residents' changing needs and behaviors. There was a lack of documentation regarding the rationale for certain interventions, such as the removal of footrests, and insufficient evidence of staff statements or thorough investigation following falls. The facility did not ensure that the environment was free from accident hazards or that adequate supervision was provided to prevent accidents for residents at high risk of falls.
Lack of Training in Dishwasher Sanitizer Testing
Penalty
Summary
The facility failed to ensure that a dietary aide, identified as Staff N, was trained and competent in testing the sanitizing solution of the low-temperature dishwasher. During an initial kitchen tour, Staff N was observed operating the dishwasher but was unable to use a test strip to measure the concentration of the sanitizer. Through a translator, Staff N stated that he had never been trained to use the test strips or informed of their purpose. The Kitchen Manager was also unaware if Staff N had received any training on using the dishwasher and testing the sanitizer. A review of the dishwasher's log for December 2024 revealed that Staff N had placed his initials on the log on 12 different days, verifying that he tested the sanitizer. However, Staff N confirmed that he did not understand what was documented on the log, indicating a lack of knowledge and training. The Kitchen Manager later provided the survey team with an employee coaching report for Staff N, highlighting his lack of knowledge about the sanitizer strip and its use in ensuring proper PPM solutions.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring the call system was within reach. The facility's policy on Universal Fall Precautions emphasizes maintaining a safe and comfortable environment, which includes keeping the call light within reach. However, observations revealed that the call light was consistently placed out of reach for a resident who was dependent on wheelchair mobility and had intact cognition. The resident expressed that she was unable to reach the call light and had to call out for help, indicating this was a frequent issue. During multiple observations, the call light was found wrapped around the side rail of the bed, behind the resident's wheelchair, and tied to the head of the bed, making it inaccessible. A CNA acknowledged forgetting to place the call light within reach, and the facility's administration confirmed that the call light should be accessible unless the resident is unable to use it. Despite the resident's ability to use the call light when requested, it was not consistently placed within her reach, leading to the deficiency.
Failure to Revise Care Plan for Resident with Cardiac Pacemaker
Penalty
Summary
The facility failed to revise the comprehensive care plans with resident-centered interventions for a resident with a cardiac pacemaker. The resident, who had been admitted and readmitted to the facility, had diagnoses including atrial fibrillation and chronic heart failure. Despite documentation in the medical record and nursing evaluations indicating the presence of a cardiac pacemaker, there was no care plan addressing the pacemaker. During an interview, the resident's daughter expressed concern that her father had not seen a cardiologist for a pacemaker check in two years, and no one had discussed the pacemaker care plan with her. The Minimum Data Set Coordinator confirmed the absence of a care plan and a physician's order for a cardiology consult. The Director of Nursing acknowledged that there should have been a care plan for the pacemaker.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for two residents, leading to deficiencies in their activities of daily living (ADLs). Resident #5, who was admitted with a fracture of the lower end of the right femur and required substantial assistance with bathing, did not receive a shower since her admission in October. Despite having a care plan that included the use of a mechanical lift and assistance from two CNAs, the facility staff reported they were unable to transfer her to the shower due to the lift. Consequently, Resident #5 only received bed baths, which did not include washing her hair, and she expressed relief after finally receiving a shower in December. Similarly, Resident #24, admitted with a history of falling and a displaced intertrochanter fracture of the right femur, also required substantial assistance with showers. Despite being scheduled for showers twice a week, Resident #24 reported not receiving any showers since her admission in November. The CNA documentation confirmed that no scheduled showers were provided, and the resident only received bed baths. The resident did not refuse showers, and the staff did not provide a reason for the lack of showers. Interviews with facility staff revealed inconsistencies in following the shower schedule and documentation. The CNAs were expected to follow the schedule and document any refusals, but there was no evidence of refusals in the records. The facility's failure to adhere to the shower schedule and provide necessary assistance resulted in the residents not receiving adequate personal hygiene care, as outlined in their care plans.
Deficiencies in Continence and Catheter Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain continence for a resident and did not maintain indwelling urinary catheters in a safe and sanitary manner for two residents. One resident, who was always incontinent of bowel and bladder, was not on a toileting program despite having intact cognitive skills. The care plan for this resident included frequent checks and assistance with toileting, but documentation showed inconsistent toileting assistance, with many shifts left blank or marked as not applicable. Interviews with the resident and her daughter revealed that the resident often sat in her bowel movements and was not checked on frequently enough, leading to discomfort and potential health risks. Two other residents with indwelling urinary catheters were not provided with proper catheter care. One resident's catheter drainage bag was observed in contact with the wheelchair's front wheel and the tubing was dragging on the floor, posing a risk of injury and infection. The drainage bag was also attached to the wheelchair armrest, compromising the resident's privacy. Despite photographic evidence and staff interviews confirming the improper handling of the catheter, the issue persisted over multiple observations. Another resident's urinary catheter drainage bag was hooked onto a trash can with the bottom resting on the floor, visible from the hallway. This improper placement was confirmed by the unit manager and the DON, who acknowledged that the drainage bag should not be on the floor or attached to a trash can. Despite being observed by a CNA, the issue was not immediately addressed, indicating a lapse in adherence to infection control standards and proper catheter care protocols.
Improper Storage and Lack of Orders for CPAP Equipment
Penalty
Summary
The facility failed to store CPAP equipment in a sanitary manner for three residents, which had the potential to cause respiratory infections. During observations, Resident #10's CPAP machine and mask were found uncovered on the nightstand, and there were no physician orders or care instructions for its use in the clinical record. Similarly, Resident #70's CPAP machine was observed on the bedside table with the mask uncovered and surrounded by food and personal items. The resident indicated that staff were responsible for the care of the machine, yet there were no physician orders or instructions in the clinical record. Resident #14's CPAP machine was also found with the mask and tubing uncovered on the nightstand. The resident, who had a history of acute respiratory failure with hypoxia and asthma, used the machine at night with staff assistance. However, there were no physician orders or care instructions documented. The Director of Nursing acknowledged that CPAP/BiPAP equipment should be stored in a plastic bag when not in use and was unaware of the lack of physician orders or directions for these residents.
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Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Port Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sun Harbor Healthcare | 1.4 mi | ★★★★★ | 0 | 0 |
| Village Place Healthcare And Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Douglas Jacobson State Veterans Nursing Home | 4.2 mi | ★★★★★ | 1 | 0 |
| Charlotte Bay Rehab And Care Center | 4.2 mi | ★★★★★ | 1 | 0 |
| Harbour Health Center | 4.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.