Resident #1 was receiving what the facility called restorative therapy when aide Staff B placed his hand under her knee and began pushing her leg toward her face. The resident felt the exercise was too aggressive and started pushing back.
"She was about to tell him to stop when she heard a pop and then had excruciating pain," according to the inspection report. "She told him, You just hurt me."
Both the resident and Staff B heard the popping sound. The aide reported the incident to a nurse, and the facility's physician ordered an X-ray of the right knee. That X-ray came back negative.
The resident continued experiencing discomfort, so the facility scheduled an appointment with an orthopedic specialist for September 11. When the specialist took new X-rays, they revealed a closed fracture of the lateral tibial plateau — the top part of the bone below the knee.
The specialist's progress note documented that the resident's pain was constant and aching, rating as high as 9 out of 10 at its worst. The pain worsened when bearing weight and improved with nothing.
Staff B told inspectors he was performing range of motion exercises with the resident's right leg, which was weaker than her left. "He said her right leg was weaker than the left, so he would help her a little with the AROM," the report states, referring to active range of motion therapy.
The problem was that Staff B wasn't supposed to be helping at all.
The Director of Rehabilitation told inspectors she had recommended only active range of motion for this resident on July 18. "She said she did not recommend PROM," referring to passive range of motion where staff move the resident's limbs. "She said resident #1 should only be doing active range of motion."
Active range of motion means the resident moves their own body parts. Passive range of motion means staff do the moving. The distinction matters because passive exercises require specific training that restorative aides don't receive.
"She said she doesn't recommend PROM to be done by restorative aides," the rehabilitation director explained to inspectors.
Physical Therapist Staff A was more direct about what went wrong. "He said the aides are not trained to do PROM," the report states. "He said Resident #1's fracture was most likely because Resident #1 was pushing her leg out while the restorative aide was pushing against it."
The physical therapist told inspectors he wouldn't expect a restorative aide to lift or place hands on a resident during active range of motion exercises. "He said the restorative aide should not assist with AROM."
The rehabilitation director acknowledged that fractures can result from passive range of motion exercises. "She said if there's osteoporosis or decreased strength, a fracture could occur."
The facility's own investigation, completed October 22, confirmed the basic facts. The restorative aide was providing range of motion therapy to the resident's lower extremities when both heard a pop. The resident complained of pain, the aide reported it to the nurse, and a physician was notified.
But the investigation didn't address why an untrained aide was performing exercises he wasn't qualified to do, or why the facility's initial X-ray failed to detect a fracture that an orthopedic specialist found weeks later.
The orthopedic specialist's notes described the injury as resulting from "an aggressive therapy exercise" during physical therapy on August 25. The specialist documented that symptoms began with "no identifiable injury (sudden onset)" — but the facility's own records clearly identified the popping sound during the aide's hands-on manipulation as the moment the injury occurred.
The resident endured more than two weeks of constant, aching pain that reached 9 out of 10 intensity before receiving an accurate diagnosis. During that time, she continued experiencing what the specialist described as "joint line pain and feelings of giving way" that worsened with weight bearing.
The inspection found the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Federal inspectors determined the violation caused actual harm to a few residents.
Staff B remains employed at the facility. The resident's current condition and treatment plan were not detailed in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Page Rehabilitation and Healthcare Center from 2025-10-28 including all violations, facility responses, and corrective action plans.
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