Page Rehab: Resident Death After Elopement Warning - FL
Federal inspectors found the facility failed to recognize the elopement risk posed by Resident #999, who had been diagnosed with bipolar disorder and paranoia. The inspection, completed January 10, resulted in an immediate jeopardy citation — the most serious level of violation.
The resident's deteriorating mental state began escalating in the days before his death. His son received a call around 11:00 a.m. one morning from the resident, who reported he had been diagnosed with bipolar disorder and paranoia. The resident told his son there was going to be a war, they needed to take cover, and to come get him immediately.
That same day, a psychiatric advanced practice registered nurse assessed the resident and reordered the antipsychotic medication Risperdal, which had been discontinued months earlier.
Two days later at approximately 5:15 p.m., law enforcement called the facility. Resident #999 had contacted them claiming he was under attack and needed to be evacuated.
Despite these clear warning signs of escalating paranoia and voiced intent to leave, facility staff never reassessed the resident's elopement risk or updated his care plan with appropriate supervision measures.
The Director of Nursing told inspectors she verified the resident's risk for elopement was not re-evaluated and the care plan was not updated with nonpharmacological interventions, including adequate supervision to maintain the resident's safety and prevent unsafe wandering and elopement.
After the resident's death, administrators struggled to explain their inaction. The Director of Nursing said she interviewed staff but was unable to determine the root cause of the elopement. "The root cause of the event was inconclusive per our findings because we do not have all the facts yet," she told inspectors.
She added that she did not know the resident required a higher level of supervision. "We did not provide that level of supervision because he did not need it and we did not substantiate the incident," she said. The Director of Nursing claimed she assessed the resident twice but did not document her assessment and concluded he did not need higher monitoring or a wander alert bracelet.
The Administrator said the facility could not reach a conclusion due to the resident's pending autopsy result. He claimed they had no way of knowing the resident was an elopement risk despite the resident's son and law enforcement alerting them of the resident's voiced intent to leave the facility.
In a particularly troubling exchange with inspectors, the Regional Director defended the staff's response. She said staff "did their due diligence in monitoring Resident #999" and claimed "a change of behavior and a change in medication were the same thing."
The facility's own quality assurance minutes revealed a fundamental misunderstanding of the situation. A Risk Management report stated: "Root cause determined that facility was not aware of the history of the resident. There was no information in the medical record nor did the family report any history of elopement."
But the inspection found the opposite. The family had reported the resident's paranoid thoughts and desire to leave. Law enforcement had been called by the resident himself expressing fear and need for evacuation.
The facility's corrective actions after the death consisted mainly of staff interviews, education on elopement procedures, and placing an additional staff member at the front door for three days. The Director of Nursing admitted she did not know through which door the resident had exited.
Notably absent from the corrective actions was any education on recognizing behavioral warning signs or properly assessing elopement risk when residents experience psychiatric symptoms.
The inspection also uncovered a widespread pest infestation throughout the facility. Inspectors found live crawling insects in cups on the memory care unit, dead insects on floors in multiple resident rooms, and an accumulation of dead insects and black substance in the dining room.
Resident #105 told inspectors she had seen "large waterbugs" in her room the previous week and had notified nursing staff, who also observed the insects.
Resident #850 said she regularly sees "big black crawling insects on the walls in the hallway" but doesn't report them because "they see them, they know they are in here."
Another resident, #22, said she frequently observes large crawling insects in her bathroom and small ones on her bedside table. "When the staff bring the meal tray and move things around on the table to place the tray, the bugs run away," she told inspectors.
Most disturbing was Resident #129's report that a bug had crawled into her orange juice on her breakfast tray the previous week.
The facility's pest control logs from July through December 2024 documented pest sightings on units and in resident rooms every month. Monthly exterminator reports showed only foundation spraying, with no targeted treatment for interior infestations.
The Maintenance Director told inspectors that residents report pest problems to him, but said no one from maintenance proactively checks for pests in the building. "The pest control company does that," he said, despite evidence the monthly service was inadequate.
The combination of failures — ignoring clear psychiatric warning signs that led to a resident's death and allowing insects to infest living spaces where vulnerable elderly residents eat and sleep — paints a picture of a facility struggling with basic safety and care standards.
The immediate jeopardy citation for the elopement incident means federal officials determined the facility's failures posed immediate risk to resident health and safety. Such citations can result in termination from Medicare and Medicaid programs if not corrected.
Page Rehabilitation and Healthcare Center is located at 2310 N Airport Road in Fort Myers. The facility must submit a plan of correction to address the violations, but for Resident #999, the warnings came too late.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Page Rehabilitation and Healthcare Center from 2025-01-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PAGE REHABILITATION AND HEALTHCARE CENTER in FORT MYERS, FL was cited for immediate jeopardy violations during a health inspection on January 10, 2025.
Federal inspectors found the facility failed to recognize the elopement risk posed by Resident #999, who had been diagnosed with bipolar disorder and paranoia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.