Adviniacare at Naples

In the surveyor’s words

From the most serious findings on record at Adviniacare at Naples, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 18, 2025

  52390 Based on observation, record review, review of facility's policies and procedures and staff interviews, the facility failed to adequately supervise 3 (Residents #1, #2 and #3) of 3 cognitively impaired residents to prevent incidents of unsafe wandering and elopement. On 12/9/24 at 2:15 p.m., Resident #1, who had a diagnosis of Dementia, severe cognitive impairment and history of attempted elopement exited the facility through the front door and set off the alarm. Staff turned off the alarm without verifying the whereabouts of residents with wander alarm bracelets. […]

• Immediate jeopardy, patternF835Apr 18, 2025

  Based on observation, record review and staff interviews, the facility administration failed to utilize its resources effectively to ensure the safety of 3 (Residents #1, #2, and #3) of 3 cognitively impaired residents and prevent multiple incidents of unsafe wandering and elopement. Resident #1 had severe cognitive impairment, was at risk for elopement and used a wander alarm bracelet. On 12/9/24 at 2:15 p.m., staff did not appropriately respond to the door alarm when Resident #1 exited the facility. On 12/9/24 at approximately 2:17 p.m., a staff member who was outside on her break found the resident wandering in the parking lot unsupervised and returned him to the facility. Resident #2 had severe cognitive impairment, was at risk for elopement and used a wander alarm bracelet. […]

• Immediate jeopardy, patternF867Apr 18, 2025

  Based on observation, record review and interview, the facility failed to thoroughly investigate elopement incidents for 3 (Residents #1, #2, and #3) of 3 cognitively impaired residents reviewed for elopement and failed to implement appropriate systemic corrective actions to prevent further incidents of unsafe wandering and elopement of mobile and confused residents. On 12/9/24 at 2:15 p.m., Resident #1 who had severe cognitive impairment and wore a wander alert bracelet exited the facility, setting off the door alarm. Staff did not appropriately respond to the alarm. A staff member who was outside on her break found the resident wandering unsupervised in the parking lot and brought him back. […]

• Actual harm, isolatedF689Nov 25, 2024

  Based on record review, review of facility policies and procedures, resident and staff interviews the facility failed to follow the established plan of care for safe transfer, resulting in an avoidable fall and fall related major injury for 1 (Resident #3) of 3 residents reviewed. The findings included: Review of the clinical record for Resident #3 revealed an admitted [DATE]. Diagnoses included morbid obesity and left artificial knee joint. The 5-day scheduled Minimum Data Set (MDS) assessment with a target date of 9/2/24 noted Resident #3 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity) for toilet transfer (Ability to safely get on and off a toilet or commode). […]

• Actual harm, isolatedF600Mar 7, 2024

  Based on observation, record review, facility policy review, resident and staff interviews and medical record and facility policy review, the facility failed to protect residents' rights to be free from neglect by failing to provide a safe environment for 2 (Residents #243 and #20) of 5 residents reviewed for avoidable falls and accidents. The findings included: The facility policy provided for Fall Prevention and Management created 7/2018 and last revised 1/2023 states: The Fall Risk Evaluation (completed on admission) will determine fall risk factors. 1. Fall risk assessments will be completed for all residents; initially on admission/readmission, quarterly, significant change and after an identified fall; 2. […]