Page Rehabilitation And Healthcare Center

F-F689.

A review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan with a review date of [DATE REDACTED] noted, The Facility will maintain a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality .

The purpose of a QAPI program is to ensure continuous evaluation of facility systems with the objective of:

Ensuring care delivery systems function consistently, accurately, and incorporate current and Evidence-based practice standards where available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Preventing deviation from care processes, to the extent possible.

Level of Harm - Immediate Identifying issues and concerns with facility systems, as well as identifying opportunities for Improvement; jeopardy to resident health or and safety Developing and implementing plans to correct and/or improve identified areas. Residents Affected - Few

On [DATE REDACTED] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) to review the incident investigation related to Resident #999's unsafe wandering and elopement, the root cause analysis and systemic corrective actions implemented to prevent recurrence.

The DON verified on [DATE REDACTED] at approximately 11:00 a.m., the resident's son called the facility to speak with her. He reported Resident #999 had been diagnosed with Bipolar disorder (mood swings ranging from depressive lows to manic highs) and paranoia (overly suspicious and thinking others are out to harm you). Resident #999 told his son there was going to be a war, they needed to take cover and to come and get him.

She verified on [DATE REDACTED], the Psychiatric Advanced Practice Registered Nurse assessed Resident #999 and re-ordered the antipsychotic Risperdal which had been discontinued in [DATE REDACTED].

She also verified on [DATE REDACTED] at approximately 5:15 p.m., law enforcement called and informed the facility Resident #999 had called them and claimed he was under attack and needed to be evacuated.

The DON verified Resident #999'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.

The Administrator and the DON said on [DATE REDACTED] the facility immediately initiated an investigation, held QAPI meetings to discuss the root cause of Resident #999's elopement, and corrective actions as appropriate to prevent further incidents of unsafe wandering and elopement of cognitively impaired residents.

The DON said after the elopement, she interviewed staff and was not able to determine the root cause of the elopement. She said, The Root cause of the event was inconclusive per our findings because we do not have all the facts yet. We did not know where the resident was found. Once we found out all the information,

we concluded it was not verified as he had no behaviors, and he had no elopement history. We did not provide that level of supervision because he did not need it and we did not substantiate the incident. The DON added she did not know the resident required that level of supervision. She said she assessed the resident on [DATE REDACTED] and [DATE REDACTED]. She did not document her assessment and Resident #999 did not need any higher level of monitoring or a wander alert bracelet (alerts staff when a resident leaves a determined safe area).

The Administrator said the facility could not reach a conclusion due to Resident #999's pending autopsy result to determine the cause of death. He said 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 as he believed he was under attack and needed to take cover.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility provided the minutes of a Risk Management/QAPI report dated [DATE REDACTED] that read, Root cause determined that facility was not aware of the history of the resident. There was no information in the medical Level of Harm - Immediate record nor did the family report any history of elopement. The facility determined that the neglect was not jeopardy to resident health or verified related to the incident based on evaluation of the medical record and history of the resident, the safety resident did not require an increased level of supervision . Facility still awaiting autopsy report and police report at this time. Residents Affected - Few

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, Leave of absence policy and procedure, elopement drills, sign-out binder at the front desk.

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 REDACTED] 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 REDACTED] and changed the resident's psychotropic medications. He said Resident #999 died of natural causes. On [DATE REDACTED] 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 REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41155 potential for actual harm Based on observation, review of facility policies and procedures, and resident and staff interviews, the facility Residents Affected - Few failed to maintain an effective pest control program and a sanitary environment free from pests in 4 of 4 units observed.

The findings included:

A review of the facility's policy Pest Control initiated 11/2018 (revised 11/19) documented It is the responsibility of the Maintenance Department to coordinate the control of pests with a company engaged in

the business of providing Pest Control Services . Pest Control Company will provide the control of roaches, ants, rodents, spiders and other insects that may be harmful to humans, equipment, supplies, or documents through direct or indirect contact or contamination.

On 1/2/25 at 8:32 a.m., during an initial facility tour, the following was observed:

1. On the secured memory care unit in the cabinet in the sitting room there were two cups with live crawling insects in the cups. The Unit Manager Registered Nurse Staff C verified the observation and discarded the cups.

Photographic evidence obtained.

2. In room [ROOM NUMBER] there was a large, brown dead insect on the floor. RN Staff C verified the

observation and removed it from the floor.

Photographic evidence obtained.

3. In the memory care unit dining room next to the piano in the corner were dead insects, and an accumulation of black substance.

Photographic evidence obtained.

4. A large dead, brown insect was observed on the floor in Resident #105's room.

On 1/2/25 at approximately 9:30 a.m., Resident #105 said there were large waterbugs as she calls them, big black things seen in her room last week. The resident said she did notify the nurse, and the nurse had observed the waterbugs as well.

5. room [ROOM NUMBER]: A large and a small brown dead insects were observed on the bathroom floor.

On 1/2/25 at 8:55 a.m., in an interview Resident #850 said she sees big black crawling insects on the walls in

the hallway. The resident said, I saw one the other day on the wall right across from my room in the hall. She said she did not tell staff because, They see them, they know they are in here.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 On 1/2/25 at 9:35 a.m., in an interview Resident #22 said she frequently observes large crawling insects in her bathroom and small ones on the bedside table. She reports it to staff. The resident said when the staff Level of Harm - Minimal harm or bring the meal tray and move things around on the table to place the tray, the bugs run away. Resident #22 potential for actual harm said she also observed crawling insects on her dresser.

Residents Affected - Few On 1/2/25 at 9:45 a.m., Resident #129 said last week a bug crawled into her orange juice on her breakfast tray. She said she had seen crawling insects on her bedside table, but she did not report it to the staff.

On 1/2/25 at 1:29 p.m., in an interview Resident #77 said he sees bugs in his room all the time by the air-conditioner vent but had not seen any in the last week.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 105864

F-F867

A review of the facility's Change in Condition Policy and Procedure with a review date of ,d+[DATE REDACTED] noted,

The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The Procedure noted, . The nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. This will also be communicated in the 24 hour/and or shift report as well . If a Level of Harm - Immediate significant change in condition occurs, a physical and or mental assessment with be completed by the jeopardy to resident health or Registered Nurse and documented in the medical record . Documentation of the change in condition will be safety present in the nurses' progress note and will continue q (each) shift for at least 72 hours . This episodic documentation will occur for, but not limited to . mental/behavioral changes . Residents Affected - Few

A review of the facility's Leave of Absence (LOA) with a review date of ,d+[DATE REDACTED] noted, It is the policy of

this facility to encourage outside socialization for the resident/patient when appropriate . A cognitively impaired resident may leave the facility with family/resident representative, unless restrictions apply, with the appropriate physician order. The facility will tract the departure and return of a resident on the Release of Responsibility for LOA form . Procedure . When LOA is to occur: Evaluate resident for a change in condition, notify physician of any concerns/changes and document in the progress note .

Review of the clinical record revealed Resident #999 was a vulnerable [AGE] year old admitted to the facility

on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] and [DATE REDACTED] 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 REDACTED], [DATE REDACTED], and [DATE REDACTED] 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 REDACTED] included to consult Psychiatry Service to evaluate and treat the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the Psychiatric Advanced Practice Registered Nurse (APRN) progress notes for [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] noted Resident #999 was oriented to Person, Level of Harm - Immediate insight and judgment were impaired, short-term and remote memory were impaired and the resident's fund of jeopardy to resident health or knowledge (used to determine if a patient has cognitive impairment) was impaired. The APRN documented safety in her notes Resident #999 did not exhibit behaviors or psychotic symptoms.

Residents Affected - Few Review of the Clinical Nurse's Note dated [DATE REDACTED] at 10:56 a.m., noted Resident #999's son called and said his dad had called him and stated that he was under attack and that the son needed to come and evacuate him. The son stated that he knew the facility had discontinued one of his father's medications a while ago and that he probably needed it back. He stated his father had been diagnosed with Bipolar disorder, paranoia, schizoaffective disorder and had been [NAME] Acted a few years ago and started on Risperidone (antipsychotic). The psychiatric provider was at the facility and was notified of the son's concerns. The Psychiatric APRN ordered to restart Risperidone 0.5 milligram twice a day.

On [DATE REDACTED] the Psychiatric APRN documented in a progress note she saw Resident #999 as it was reported to her the resident was unstable requiring psychiatric assessment. Resident #999 appeared agitated, upset. His thought process was somewhat disorganized. His insight and judgement were impaired. The resident was oriented to person, with impaired recall and short term memory. Attention span and concentration were poor. Fund of knowledge was impaired.

The practitioner documented the resident was unstable requiring medication changes. She wrote, As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying psychosis disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms.

On [DATE REDACTED] at 1:59 p.m., a nursing progress note documented Resident #999 was confused, and independent for all transfers, Will continue to monitor resident for behavior.

The note did not describe what behavior was being monitored.

On [DATE REDACTED] at 5:23 p.m., a nursing progress documented the Fort [NAME] Police called the facility to say that Resident #999 had call them to report that he needed to be taken out of the facility. The resident said he was

in danger of the war and needed evacuation.

The police arrived at the facility and visited with the resident for about five minutes and left.

There was no documentation on [DATE REDACTED] Resident #999's risk for elopement was re-evaluated when the resident with a psychiatric history exhibited paranoid behavior and expressed desire, and intent to leave the facility.

The care plan was not updated to address the acute change in behavior and ensure adequate supervision to maintain the resident's safety and prevent elopement.

On [DATE REDACTED] at 3:46 a.m., a nursing progress note documented Resident #999 was in bed and no behavior was observed at that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On [DATE REDACTED] at 5:20 p.m., Licensed Practical Nurse (LPN) Staff D documented in a Late Entry Clinical Nurse Note the resident's mood was stable and pleasant that morning. He was sitting near the nurse's station after Level of Harm - Immediate lunch. At around 4:15 p.m., he went to the resident's room to administer medications. Resident #999 was not jeopardy to resident health or there. He asked the assigned Certified Nursing Assistant to help him search for the resident from room to safety room and unit by unit and they could not find him. At 4:35 p.m., he notified the supervisor on duty. At around 4:40 p.m., the supervisor called a code pink for missing resident according to facility's protocol. Residents Affected - Few

On [DATE REDACTED] at 8:15 p.m., a nursing progress note documented the facility notified law enforcement that Resident #999's was missing at approximately 5:00 p.m. Law enforcement arrived at the facility at 5:15 p.m.

The resident's wheelchair was found outside by the Ford Unit. The police received a call for a possible civilian on [NAME] street just down from the facility. The police left to go to the area. On [DATE REDACTED] at approximately 8:15 p.m., a detective notified the facility the resident was found deceased in a bar parking lot just down the road from the facility.

On [DATE REDACTED] at 10:15 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) related to Resident #999's elopement and the facility's process to prevent unsafe wandering and elopement.

The DON said the facility used to have a sign out book at the front desk but they did not require residents to sign out if they just wanted to sit outside in front of the facility. Residents were free to get around, go outside, and sit there without staff supervision and there was no monitoring camera outside.

The DON said Resident #999 lacked capacity. She verified on [DATE REDACTED] Resident #999's son called and told her his father was acting fearful. He thought he was in the war and said he had to leave the facility. He requested the son come and get him. The son told her his father was prescribed antipsychotic medication for

a diagnosis of schizophrenia and he was paranoid. He also was diagnosed with Bipolar disorder. He thought

he should be put back on Risperidone, the antipsychotic medication which had been prescribed for paranoia.

She said that same day the Psychiatric APRN assessed the resident and re-ordered the Risperdal (Risperidone). That afternoon, the police called the facility to inform them Resident #999 had called them requesting to be evacuated as he thought there was going to be a war and the staff were going to kill him.

The police then came to the facility and spoke with Resident #999 for five minutes. They said he was fine and they left.

The DON said she checked on the resident the next day and he was fine. She did not tell the staff of the concerns voiced by Resident #999's son. She did not feel he needed increased supervision.

She verified the resident's elopement risk was not re-evaluated despite knowledge of the psychiatric history and expressed intent to leave the facility. She said the facility was not aware of the resident's elopement history. He had previously eloped from the Assisted Living Facility where he resided and was trying to get back to Missouri. He was [NAME] acted (involuntary hospitalization for mental illness).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The Administrator said on [DATE REDACTED] at approximately 3:30 p.m., to 4:00 p.m., the Maintenance Assistant (Tech) observed Resident #999 outside to the left of the door. The resident was not visible from the front Level of Harm - Immediate desk. He did not sign out in the leave of absence log per policy. The Maintenance Assistant tried to bring the jeopardy to resident health or resident back into the building but Resident #999 refused to go back inside. He left the resident outside and safety did not notify anyone.

Residents Affected - Few The Administrator said LPN Staff I observed Resident #999 sitting outside to the side of the building from a window of the Ford Unit. She did not report it to anyone.

The Administrator said the facility did not have a policy specifying which residents could come and go from

the facility. Resident #999 was not an elopement risk. He enjoyed the freedom to get fresh air.

On [DATE REDACTED] at 1:28 p.m., in an interview LPN Staff D said on [DATE REDACTED] no one informed him of the resident's change in mental status or update to his medications. He became aware the resident had called the police

on [DATE REDACTED] through word of mouth.

On [DATE REDACTED] at 3:52 p.m., in an interview Certified Nursing Assistant (CNA) Staff E said LPN Staff D and another CNA told her Resident #999 had called the police on [DATE REDACTED] but no one told her she needed to supervise the resident. She said Resident #999 never left the unit. If she had seen him outside she would have brought him back in as no resident should be left unsupervised outside.

On [DATE REDACTED] at 4:17 p.m., in an interview the Maintenance Tech said he had never seen Resident #999 outside of the facility prior to [DATE REDACTED]. When he saw the resident outside around 3:30 p.m., to 4:00 p.m., he asked the resident if he was ok, and he said he was. He said, I did not try to get him to go inside. I did not bother because he gets very agitated and would swear at you. The Maintenance Tech said, If I had known

he was not allowed to go outside, I would have gotten him and brought him inside. He said he tells residents to stay away from the road. The road is so close and he does not want them to get hurt.

On [DATE REDACTED] at 4:41 p.m., in a telephone interview Resident #999's son said, I notified the facility the day

before he passed, that he wanted to flee the facility by any means possible. He thought someone there was going to kill him. He was a flight risk and wanted to elope. He told me he wanted to get out of the facility because they were going to kill him. He called 911 and told them the same information. I spoke to the DON

on [DATE REDACTED] and told her that my father wanted me to immediately evacuate him from the facility because they were going to kill him. I told her they needed to take precautions and adjust his medications. He was hallucinating thinking people were going to kill him. I told them he would try and find a way out of the facility.

The son said his father had Dementia; the facility should have monitored him.

On [DATE REDACTED] at 10:00 a.m., in an interview Unit Manager Registered Nurse Staff B said LPN Staff D and CNA Staff E were aware the police came to the facility, everyone saw them. She overheard Resident #999 asking

the police to take him, he was in danger. The resident said to the police officers, I want you to remove me from the facility. She said she did not relay that information to the direct care staff. She did not tell them about the resident's onset of behavior and expressed intent to leave the facility and did not instruct them to supervise the resident. She did not see a reason to place the resident on one-to-one supervision or every 15 minutes checks just because he called the police one time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On [DATE REDACTED] at 5:50 p.m., in a telephone interview Resident #999's attending physician said it was hard to say if the resident was safe to go outside on his own. She was not aware of the change in his behavior but Level of Harm - Immediate perhaps the Physician Assistant was notified. jeopardy to resident health or safety On [DATE REDACTED] at 10:16 a.m., in an interview the Physician Assistant said, It is hard to say if (Resident #999) was safe to be outside. He said the resident lacked capacity; he was confused but compliant. He was safe to go Residents Affected - Few outside, right out the front door where staff could see him. When asked if it was safe for Resident #999 to be outside on the side of the building, out of view of staff at the front desk, the Physician Assistant did not reply.

On [DATE REDACTED] at 12:47 p.m., in an interview LPN Staff I said she did not know Resident #999. On [DATE REDACTED] at approximately 3:45 p.m., she was walking down the hallway and observed residents 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 yellow shirt he was wearing.

On [DATE REDACTED] 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 REDACTED]. The Social Service Director said no one told her the son had called and voiced concerns about his father wanting to leave the facility. No one told her the resident had called the police requesting they remove him from the facility. The Social Service Director printed a copy of

the alerts report for [DATE REDACTED] through [DATE REDACTED]. The report listed Resident #999's new antipsychotic medications ordered on [DATE REDACTED] but did not document the resident's paranoid behavior and voiced intent to leave the facility.

On [DATE REDACTED] 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 REDACTED] at 11:40 a.m., the Regional Director provided a care plan with a canceled date of [DATE REDACTED] 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 REDACTED] with a revision date of [DATE REDACTED] and a target date of [DATE REDACTED] 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 REDACTED] when the confused resident voiced intent to leave the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41155 Residents Affected - Few Based on observations, review of facility policies and procedures and staff interviews, the facility failed to ensure medications were stored in a safe and secure manner for 2 (Residents #950 and 900) of 10 rooms observed and 1 (Ford Unit) of 4 units observed.

The findings included:

A review of the facility's policy Medication Administration initiated 6/2018 (revised 9/6/23) documented Medications shall be administered in a safe and timely manner, and as prescribed by the physician . Medications and biologicals shall be administered by the same licensed staff member who prepared the dose for administration and will be given as soon as possible after the dose is prepared .

On 1/2/25 at 8:32 a.m., during an initial tour of the facility the following was observed:

1. Resident #950 was noted to have a clear, plastic medication cup on her bedside table. The medication cup contained a long, white pill inside. Resident #950 said it was her potassium pill, and she was waiting for someone to break it in half for her.

Photographic evidence obtained.

On 1/2/25 at 8:37 a.m., Unit Manager Registered Nurse (RN) Staff B verified the pill was left at the resident's bedside and said she would speak with the resident's nurse. RN Staff B said the pill should have been administered and not left with the resident.

Review of the clinical record revealed Resident #950 did not have an order to self-administer medications.

2. On 1/2/25 at 9:00 a.m., Resident #900 was noted to have an Albuterol Sulfate inhaler on the bedside table. The resident was not in his room and the inhaler was left unattended.

Photographic evidence obtained.

On 1/2/25 at 9:05 a.m., RN Staff B was notified of the inhaler left at the bedside and confirmed that the inhaler should not have been left at the bedside.

Review of the clinical record revealed Resident #900 had not been assessed to safely self-administer the medication and had no physician order to do so.

3. There was a round orange, unidentified pill on the floor outside of room [ROOM NUMBER]. RN Staff B was notified and removed the pill.

Photographic evidence obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 4. On 1/2/25 at 9:29 a.m., a large, long, white pill was observed on the floor of the Ford unit next to the sitting room entrance. Housekeeper Staff G was standing at the entrance to the sitting room and was informed Level of Harm - Minimal harm or there was a pill on the floor, but did not attempt to remove it. Unit Manager RN Staff A was notified and potential for actual harm removed the pill.

Residents Affected - Few Photographic evidence obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 22 105864 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41155 safety Based on record review, review of facility's policies and procedures, the facility failed to thoroughly Residents Affected - Few investigate an elopement incident for 1 (Resident #999) of 3 sampled residents reviewed for elopement, and failed to implement systemic appropriate corrective actions to prevent further incidents of unsafe wandering and elopement of mobile confused residents.

On [DATE REDACTED] the facility failed to ensure Resident #999's safety when the son and law enforcement notified the facility the resident called, said he was under attack, voiced intent to leave the facility and requested they come and get him.

On [DATE REDACTED] at 4:35 p.m., staff became aware Resident #999 was missing and contacted law enforcement to assist with the search.

On [DATE REDACTED] at approximately 8:15 p.m., law enforcement notified the facility Resident #999 was found deceased , in a parking lot approximately half a mile from the facility.

The facility's investigation did not include the failure to reassess the resident's elopement risk with the onset of paranoid behavior. The systemic corrective actions did not include documentation of behaviors and appropriate actions to ensure residents safety with the onset of new behaviors that may lead to elopement.

The facility failure to have an effective Quality Assurance and Performance Improvement program that identify quality deficiencies and implement appropriate corrective actions created a likelihood of unsafe wandering and elopement of cognitively impaired, confused residents which could result in serious harm, serious injuries or death of the residents.

This failure resulted in the determination of isolated ongoing Immediate Jeopardy.

On [DATE REDACTED] at 10:11 a.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ).

The finding included:

Cross reference to