Inspection·December 8, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision and interventions to prevent multiple falls for 2 (Residents #20 and Resident #30 ) of 3 residents surveyed for falls. The findings included: Review of the facility policy Fall Prevention and Management reviewed on 6/2023 shows post fall management included: In the event a resident has fallen and /or is found on the ground, a complete head to toe assessment must be performed. Obtain vital signs, obtain neurological checks for any unwitnessed fall or any fall with evidence of head injury. The nurse will complete an incident report; contact physician and family and document in the medical record, including time and person spoken with. Update care plans with new interventions or delete those interventions no longer appropriate. Review of the Falls Management and Prevention revised 5/17/2022: Implement goals and interventions with resident/family for inclusion in the interdisciplinary Plan of Care based on individual needs after attempting to determine possible causes. Updated care plan with new interventions or deletethose interventions no longer appropriate. The Minimum Data Set (MDS) 5-day with an Assessment Reference Date (ARD) of 8/24/23 shows Resident #20 was at risk for falls and had fallen within a month before being admitted for care by the facility. Review of Resident #20's Baseline care plan revealed the facility initiated fall interventions on 8/18/23 to prevent falls: anticipate needs, call light in reach, non-skid socks when out of bed, frequently used items in reach, safe environment, bed in lowest position. Review of Resident #20's activities of daily living (ADLs) care plan initiated on 8/30/23 revealed Resident #20 required extensive assistance of two staff for moving in bed and transferring from bed to wheelchair. The baseline care plan revealed Resident #20 was cognitively impaired with dementia. Incident report dated 8/28/23 at 9:18 p.m. revealed Resident #20 was alone in her room and fell trying to move the dinner tray. The resident reported she hit the back of her head and was sent to the hospital. The facility identified predisposing factors for the fall were confusion, memory impairment, incontinence and gait imbalance. Updated care plan interventions include the resident asking for assistance to remove the tray from room. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 105864 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 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)