Inspection·July 1, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review and staff interviews, the facility failed to implement individualized interventions, including supervision to prevent avoidable falls for 1 (Resident #2) of 3 residents reviewed for accidents. Review of the clinical record for Resident #2 revealed an admission date of 5/22/25. Diagnoses included cerebral infarction, muscle wasting and atrophy, difficulty walking, lack of coordination, and aphasia (difficulty speaking).Review of the admission Nursing assessment dated [DATE] revealed Resident #2 had impaired vision, was incontinent of urine once or twice daily, during the day and nighttime.Review of the baseline care plan dated 5/23/25 revealed Resident #2 was always incontinent of bladder and bowel and required the assistance of 2 staff for transfer, and ambulation.The care plan noted the resident was at risk for falls related to impaired cognition, medication use, poor safety awareness, cardiac disease and decreased mobility. The goal was to minimize risk of falls. The interventions as of 5/23/25 included:Anticipate and meet the resident's needs, ensure the call light is within reach and encourage resident to use it to call for assistance, bilateral fall pads when in bed, placing under the bed when out of bed.Review of the Bowel and Bladder assessment dated [DATE] revealed the 3 Day Tracking Results showed conflicting information. The form noted Resident #2 was always incontinent of bladder and bowel and also noted the resident was continent of bowel and bladder. Resident #2 had impaired mobility/ambulation. The suspected cause of the incontinence was Functional (decreased mental awareness/decrease of loss of mobility or personal unwillingness).The treatment plan was, Check and change program- designed for residents who are physically unable to sit on toilet or have cognitive impairment or behaviors that make it difficult to use.Review of the facility incident log revealed Resident #2 had multiple falls from 5/27/25 through 6/4/25.Review of the fall investigations revealed:Fall #1:On 5/27/25 at 8:40 p.m., Resident #2 was found on the floor in her room. Resident #2 said she was trying to ambulate to the bathroom.On 5/27/25 the care plan was updated to post a sign to remind Resident #2 to call for help.Review of the Bladder Continence Log revealed on 5/27/25 Resident #2 was toileted at 12:25 a.m., then approximately 11 hours later at 11:19 a.m., at 3:59 p.m., and at 11:47 p.m.There was no documentation the fall investigation included the lack of documentation Resident #2 was provided incontinent care approximately 4.5 hours prior to the fall.Fall #2:On 5/28/25 at 6:09 p.m., Resident #2 was found on the floor in her room. Resident #2 stated, I wanted to go to the bathroom.On 5/28/25 the care plan was updated to ensure Resident #2 had nonskid socks, slippers, or shoes when she's out of bed for ambulation or mobilization in wheelchair; keep frequently used items within reach; and maintain a safe environment, free of clutter and wet floors, and ensure adequate lighting.Review of the Bladder Continence Log revealed on 5/28/25 Resident #2 was toileted at 9:24 a.m., 4:46 p.m., and 11:51 p.m.On 5/29/25 the facility performed a medication regimen review with reduction in the resident's Seroquel (antipsychotic) medication.Fall #3:On 5/30/25 at 10:00 a.m., Resident #2 was found on the floor in the bathroom. She stated she was (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 2 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 07/01/2025 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)