Page Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to provide restorative nursing services as specified in the care plan resulting in a fracture for 1 (Resident #1) of 3 selected residents who receive restorative nursing services.

Inspectors wroteBased on observation, staff interviews, and record reviews, the facility failed to follow proper sanitation and food handling practices to prepare, distribute, and serve food in a safe and sanitary manner to prevent potential outbreak of foodborne illness.

Inspectors wroteBased on observation, review of facility policy and procedures and resident and staff interviews, the facility failed to maintain a homelike and sanitary environment by failing to properly store personal care items in shared spaces.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident received treatment and care in accordance with physician order and plan of care plan for 1 (Resident #60) of 1 resident reviewed for post-surgical care.

Inspectors wroteBased on observation, review of facility policy and procedures, record review and staff and resident interview, the facility failed to follow physician orders for the application of positioning devices for 2 (Resident #116 and #39) of 4 residents reviewed with a limitation in range of motion (ROM). This had the potential to cause pain and further losses in ROM.

Inspectors wroteBased on observation, record review, staff and resident interviews and review of facility policy and procedures, the facility failed to ensure medications were stored safely and securely for 1 (Resident #140) of 5 residents reviewed for medications. This failure had the potential for other residents to have access to medications that could potentially be harmful to them.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from neglect by failing to re-evaluate Resident #999's elopement risk and prevent unsafe wandering and elopement with onset of paranoid behaviors such as distrust of staff and verbal expression of desire and intent to leave the facility. Resident #999 diagnoses included dementia and psychosis. The resident used a wheelchair for mobility and was ambulatory with supervision. On [DATE] the facility neglected to re-evaluate the resident's elopement risk and neglected to adequately supervise Resident #999 when the resident's son and law enforcement reported Resident #999 called them believing he was under attack and requested they come to evacuate him. [...]

Inspectors wroteBased on clinical record review, review of facility's policies and procedures, resident representative and staff interviews the facility failed to recognize risk factors for elopement and adequately supervise 1 (Resident #999) of 3 sampled confused residents when Resident #999 exhibited new symptoms of paranoia and voiced intent to leave the facility. On [DATE] the facility failed to implement adequate supervision when Resident #999's son and law enforcement notified the facility the resident reported he was under attack and requested they come to evacuate him. On [DATE] at approximately 3:30 p.m., Resident #999 who was cognitively impaired was not supervised and exited the facility. Facility staff saw him outside to the right of the building and did not intervene. On [DATE] at 4:30 p.m., facility staff could not find Resident #999 and notified law enforcement to assist with the search. [...]

Inspectors wroteBased on record review, review of facility's policies and procedures, the facility failed to thoroughly 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] 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] at 4:35 p.m., staff became aware Resident #999 was missing and contacted law enforcement to assist with the search. On [DATE] 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. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure a safe, clean, comfortable and sanitary environment for residents in 4 of 4 units observed.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, review of facility policies and procedures, and resident and staff interviews, the facility failed to maintain an effective pest control program and a sanitary environment free from pests in 4 of 4 units observed.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, interview, and review of the facility policies, the facility failed to ensure treatment and services for prevention and management of pressure ulcers were provided in accordance with accepted standards of practice for 3 (Resident #42, #107 and #160) of 8 residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, record review, staff interview and resident interviews, the facility failed to provide food that is palatable, attractive, and at an appropriate temperature for 7 residents (#14, #38, #67, #77, #116, #141, #91) of 7 residents reviewed for dietary needs.

Inspectors wroteBased on observation, record review and staff interview the facility failed to treat residents with respect and dignity for 1 (Resident #110) of 28 cognitively impaired residents on the memory care unit.

Inspectors wroteBased on record review, interview and facility policy, the facility failed to refer 1 (Resident #34) of 4 resident reviewed for a Preadmission Screening and Resident Review (PASARR) level II screening after a newly diagnosed mental disorder. Resident #34 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with ARD of 6/21/22 listed diagnoses of Urinary Tract Infection, Stroke, Non-Alzheimer's Dementia, Hemiplegia, Anxiety. The Quarterly MDS review on 12/20/22 first noted resident to be diagnosed with Schizophrenia.

Inspectors wroteBased on observation, review of facility policy, record review and staff interview the facility failed to provide the necessary care and services to maintain personal hygiene for 1 (Resident #110) of 6 residents reviewed for ADL care.

Inspectors wroteBased on observation, record review, resident, staff and physician interview, the facility failed to change Central Venous Catheter dressing in accordance with physician's orders for 1 (Resident #76) of 1 resident reviewed for Central Venous Catheter. The finding Included: Facility policy titled Central Venous Catheter Dressing Changes, revised 1/17/2019, stated Central Venous Catheter dressings will be changed at specific intervals, or when needed to prevent catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Preparation indicated to verify with state nurse practice act the scope of practice for Registered Nurses and Licensed Practical Nurses regarding this procedure. A provider order is not needed for this procedure. Dressing must stay clean, dry, and intact. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide oxygen therapy, in accordance with physician orders for 1 (Resident #72) of 1 sampled resident reviewed. The failure to adequately maintain the oxygen concentrator had the potential to cause inadequate oxygenation for a resident dependent on oxygen.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to maintain documentation of a thorough interdisciplinary approach to address the mental and psychosocial status of 2 (Residents #103 and #133) of 5 residents reviewed to ensure their highest practicable mental and psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure collaboration of Hospice services for 3 (Residents #140, #139, and #88) of 4 residents reviewed of the 12 residents currently receiving Hospice services. Hospice is a specialized form of medical care that provides comfort and quality of life while facing a life-limiting disease or terminal condition. Coordination of care between facility services and Hospice services to ensures the highest level of comfort and care during the end-of-life.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to maintain food preparation equipment in a clean and sanitary manner; failed to maintain a minimum wash temperature in the dishwasher to ensure effective sanitization of dinnerware. The facility failed to maintain nourishment room and equipment in a clean safe and sanitary manner to prevent contamination for 3 of 3 nourishment rooms. The lack of sanitation in the kitchen and nourishment rooms has a potential to affect all residents consuming an oral diet.

Inspectors wroteBased on observation, record review, and interview, the facility failed to make prompt efforts to initiate and/or resolve grievances and keep resident appropriately apprised of progress towards resolution for 8 (Resident #32, #131, #145, #79, #72, #86, #92, and #129) of 8 residents for Residents' grievances and grievances filed through resident council meetings.

Inspectors wroteBased on record review and staff interview, the facility failed to complete, encode, and transmit Discharge Minimum Data Set (MDS) assessments for 3 (Resident #3, #4 and #6) of 4 residents reviewed for resident assessments.

Inspectors wroteBased on records reviewed and staff interviews the facility failed to develop and implement a baseline care plan for each resident admitted that included the instruction needed to provide effective and person-centered care for 5 (Residents # 12, # 41, #115, #116, and #132) of 5 residents reviewed for baseline care plan.

Inspectors wroteBased on observation and staff interview the facility failed to ensure appropriate storage of residents' medications in 3 of 3 medication carts reviewed. The facility also failed to ensure 1 ([NAME] unit) of 2 medication rooms was free from expired medications.

Inspectors wroteBased on observation, policy review, resident and staff interviews, the facility failed to ensure residents receive food and drink that are palatable, attractive and at a safe and appetizing temperature for 9 (Resident #30, #151, #115, #17, #120, #12, #32, #60, #116) of 9 residents reviewed.

Inspectors wroteBased on observation, resident and staff interview, the facility failed to honor food preferences for select menus for 4 (residents#50, #43, #311, and #115) of 4 residents reviewed.

Inspectors wroteBased on observation, review of facility's policies, resident and staff interview, the facility failed to maintain a safe, sanitary, and comfortable environment for residents. The facility failed to ensure proper storage and cleaning of residents' equipment, failed to store resident personal care items in a sanitary manner, failed to repair damaged furniture in resident rooms and make necessary repairs in bathrooms. Not maintaining a sanitary environment has the potential for cross contamination.

Inspectors wroteBased on observation, staff and resident interviews, and record review, the facility failed to have an effective pest control program and ensure a pest free living environment for residents.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure timely assistance with dining to maintain dignity for 2 (Residents #67 and #44) of 4 dependent residents observed during dining.

Inspectors wroteBased on observation, resident and staff interview, the facility failed to consistently ensure the call light was within residents' reach to request for assistance as needed for 3 (Resident #87, #91 and #60) of 35 sampled residents.

Inspectors wroteBased on record review, resident and staff interview the facility failed to promptly arrange services following the loss of dentures for one (Resident #129) of one resident reviewed for dental care out of 35 sampled residents.