Page Rehabilitation And Healthcare Center
PAGE REHABILITATION AND HEALTHCARE CENTER in FORT MYERS, FL — inspection on January 10, 2025.
Found 8 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.
Inspection Findings
substance.
responsible for cleaning the ice machine.
Photographic evidence obtained.
- The bottom of two storage drawers of the refrigerator of the secured unit were coated with a
dried, brown substance in the bottom of the drawers.
Three cartons of milk stored in the refrigerator had an expiration date of 12/30/24.
The bottom of the freezer had a dried, yellow substance. On 1/2/25 at 9:28 a.m., in an interview RN Staff C said she was uncertain who was responsible to clean the refrigerator and discarded the expired milk.
Photographic evidence obtained.
- room [ROOM NUMBER]: The shared bathroom had a wash basin stored in the sink.
Residents' unlabeled personal items were stored on top of the sink.
On 1/2/25 at 3:02 p.m., in an interview, the Director of Nursing (DON) said the facility had no policy for the storage of personal items but the expectation was for resident personal items to be labeled with the resident name and placed in a plastic bag and stored in the closet or nightstand.
The DON said she had recently educated the staff and gave them small zip lock bags to put toothbrushes, toothpaste and other small items when not is use.
105864 01/10/2025
Page Rehabilitation and Healthcare Center 2310 N Airport Road Fort Myers, FL 33907
jeopardy to resident health or [DATE] at approximately 3:45 p.m., she was walking down the hallway and observed residents safety outside just to the right of the front doors by the patio of the Ford unit.
After Resident #999 eloped she realized he was one of the residents she observed outside from the description of the bright
On [DATE] at 5:50 p.m., in a telephone interview Resident #999's attending physician said the resident had a history of paranoia but she was not aware the resident had a history of elopement.
The physician said it was hard to say if the resident was safe to go outside on his own or not.
On [DATE] at 10:08 a.m., in an interview Unit Manager LPN Staff J said Resident #999 was not an elopement risk, he had never tried to leave the facility.
She said, We had no way to think he would get up and leave the facility. He had the right to go outside. LPN Staff J said they would be restraining the resident if they tried to stop him from going outside. LPN Staff J said, He had the right to leave, and the right to fall.
Isn't it what you people always say? He did not have a lack of capacity when he was here.
When showed the certificate of incapacity signed by two different physicians, the Unit Manager turned her head and did not answer any additional questions.
On [DATE] at 10:16 a.m., in an interview the Physician Assistant said Resident #999 spoke about the war a lot since he met him. He did not always make sense; he was confused but always compliant. He said it was hard to say if Resident #999 was safe to be outside as residents' rights come into play and they have residents who go outside for fresh air. He said Resident #999 was safe to go outside, right out the front door if staff could see him.
The resident never said he wanted to leave the facility.
On [DATE] at 2:25 p.m., in an interview the Social Service Director said she was responsible to update the care plan for changes in behavior.
The nurses document changes in condition in the alerts section of the electronic clinical record.
She follows up on what nursing documents.
She said there was no clinical alert documented for Resident #999 on [DATE].
The Social Service Director said no one told her the son had called and voiced concerns about his father. No one told her the resident had called the police.
The Social Service Director printed a copy of the alerts report for [DATE] through [DATE].
The report listed Resident #999's new antipsychotic medications for [DATE] but did not document the resident's paranoid behavior and voiced intent to leave the facility.
On [DATE] at 10:44 a.m., a joint interview was conducted with the Administrator, the DON and the Regional Director.
The Regional Director said the DON saw the resident the day he eloped and he was fine, his usual self.
She asked the DON if she documented her assessment of the resident, the DON said it was the one time she did not do it.
105864 01/10/2025
Page Rehabilitation and Healthcare Center 2310 N Airport Road Fort Myers, FL 33907
one told her the son had called and voiced concerns about his father wanting to leave the facility. No
jeopardy to resident health or Social Service Director printed a copy of the alerts report for [DATE] through [DATE].
The report safety listed Resident #999's new antipsychotic medications ordered on [DATE] but did not document the resident's paranoid behavior and voiced intent to leave the facility.
On [DATE] at 10:24 a.m., in a follow up interview related to the lack of supervision resulting in Resident #999's elopement, the Administrator said the resident died of natural causes. He said the police came to the facility and did not recommend more supervision.
The Administrator said, Why didn't the police tell us that he needed more supervision? They thought he was fine.
The police said he was safer at the facility.
The Administrator said at the time Resident #999 wandered off the property, he was safe to be outside unassisted per their assessment. A lot of people saw the resident, and no one, including the police, the psychiatric APRN recognized he was an elopement risk.
On [DATE] at 11:40 a.m., the Regional Director provided a care plan with a canceled date of [DATE] which noted Resident #999's well-being was promoted by spending time outdoors, at times as well as watching television.
The diagnoses listed included unspecified dementia.
The care plan initiated on [DATE] with a revision date of [DATE] and a target date of [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia.
The care plan did not include provision for supervision for outdoor activities and was not revised on [DATE] when the confused resident voiced intent to leave the facility.
105864 01/10/2025
Page Rehabilitation and Healthcare Center 2310 N Airport Road Fort Myers, FL 33907
was notified and removed the pill.
105864 01/10/2025
Page Rehabilitation and Healthcare Center 2310 N Airport Road Fort Myers, FL 33907
history of the resident, the resident did not require an increased level of supervision .
Facility still
jeopardy to resident health or safety The facility's interventions consisted of staff interviews, education to the staff on resident elopements, code Pink for missing resident, the elopement binder, elopement policy and procedure,
The DON said she conducted the elopement drills; she placed an additional staff at the front door for three days to monitor since she did not know through which door the resident exited the facility.
The facility's corrective actions did not include staff education on ensuring the elopement evaluations accurately reflected residents' risk factors, or recognizing, documenting and implementing adequate supervision with onset of behavior that may lead to unsafe wandering and elopement.
On [DATE] at 10:24 a.m., in an interview related to the neglect of Resident #999 and systemic interventions to prevent further incidents of unsafe wandering and elopement of mobile, confused and cognitively impaired residents, the Administrator said the Psychiatric APRN (Advanced Practice Registered Nurse) assessed Resident #999 on [DATE] and changed the resident's psychotropic medications. He said Resident #999 died of natural causes. On [DATE] law enforcement came to check on Resident #999 when he called them to say he was under attack and requested assistance to leave the facility.
They did not recommend increased supervision of the resident.
On [DATE] at 10:44 a.m., in an interview the Regional Director said the staff did their due diligence in monitoring Resident #999.
She said a change of behavior and a change in medication were the same thing.
She said, You put a label on it but the facility did document and kept an eye on this resident throughout the shift.
105864 01/10/2025
Page Rehabilitation and Healthcare Center 2310 N Airport Road Fort Myers, FL 33907
During random observations in the facility conference room on 1/2/25, 1/3/25 and 1/6/25, small flying insects were observed.
Review of the pest control Service Inspection Reports dated 12/18/24, 12/4/24, 11/6/24, 10/16/24, and 10/3/24 revealed the exterminator documented, Today I applied a liquid insecticide around the foundation of your building to control any type of bugs crawling around or trying to get inside.
Review of the facility Pest Sighting Log from July 2024 through December 2024 documented pests were observed on the units, and in residents' rooms each month.
On 1/6/25 at 12/29 p.m., in an interview the Maintenance Director said there were pest logbooks at each nursing station.
The pest control company checks the logbooks when they are here.
Residents come to us and notify us if they see anything or have a problem with pests.
The Pest Control company is here monthly but if needed they will come when notified.
The Maintenance Director said he checks the logbooks to see if he needs to spray as well and said the residents have not reported any pest sightings to him. If anyone sees anything they notify him. He said no one from maintenance goes around the facility to check if there are pests in the building, the Pest Control company does that.
During random observations in the facility conference room on 1/2/25, 1/3/25 and 1/6/25, small flying insects were observed.
Review of the pest control Service Inspection Reports dated 12/18/24, 12/4/24, 11/6/24, 10/16/24, and 10/3/24 revealed the exterminator documented, Today I applied a liquid insecticide around the foundation of your building to control any type of bugs crawling around or trying to get inside.
Review of the facility Pest Sighting Log from July 2024 through December 2024 documented pests were observed on the units, and in residents' rooms each month.
On 1/6/25 at 12/29 p.m., in an interview the Maintenance Director said there were pest logbooks at each nursing station.
The pest control company checks the logbooks when they are here.
Residents come to us and notify us if they see anything or have a problem with pests.
The Pest Control company is here monthly but if needed they will come when notified.
The Maintenance Director said he checks the logbooks to see if he needs to spray as well and said the residents have not reported any pest sightings to him. If anyone sees anything they notify him. He said no one from maintenance goes around the facility to check if there are pests in the building, the Pest Control company does that.
105864
Review of the clinical record revealed Resident #999 was a vulnerable [AGE] year old admitted to the facility on [DATE] following hospitalization for altered mental status.
Diagnoses included unspecified Dementia without behavioral disturbance, Psychotic disturbance, mood disturbance, Major Depressive Disorder, Anxiety, Bipolar II disorder (mood swings ranging from depressive lows to manic highs), and Generalized Muscle Weakness.
The Admission Minimum Data Set (MDS) assessment with a target date of [DATE] noted Resident #999's cognition was moderately impaired with a Brief Interview for Mental Status of 09 (Moderate level of cognitive impairment).
The resident was ambulatory with supervision or touching assistance.
The care plan initiated on [DATE] noted the resident had impaired cognitive function/dementia or impaired thought processes related to dementia.
The interventions included to monitor, document and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, mental status.
On [DATE] and [DATE] two physicians evaluated the resident and signed an incapacity statement noting Resident #999 lacked the capacity to give informed consent and make healthcare decisions based on advanced stage dementia and confusion.
The elopement evaluations completed on [DATE], [DATE], and [DATE] noted the resident was ambulatory or able to self-propel in a wheelchair.
The potential risk factors for elopement, such as history of elopement, desire to return home, expressed desire to leave, attempted elopement, and psychiatric history were not checked off on the elopement evaluation forms.
Each time the facility determined Resident #999 was not at risk for elopement.
The Physician's orders dated [DATE] included to consult Psychiatry Service to evaluate and treat the resident.
105864
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 105864 B.
Wing 01/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Page Rehabilitation and Healthcare Center 2310 N Airport Road Fort Myers, FL 33907
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.