Naples Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Naples Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF726Aug 25, 2023

  Based on observations, record review, review of facility's policies and procedures, and staff interviews, review the facility failed to have processes in place to ensure nursing staff were trained and competent to safely use mechanical lifts for resident transfers. On 8/12/23 Resident #1 sustained a fall during transfer with a mechanical lift resulting in a transfer to the hospital. Resident #1 suffered spinal and pelvic fractures. The Certified Nursing Assistants (CNAs) transferring the resident had no documentation of training and competency in the use of the mechanical lift. […]

• Immediate jeopardy, isolatedF689Mar 6, 2026

  Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to prevent avoidable accidents by failing to ensure the appropriate storage of ignition devices for four (Residents #37, #67, #118 and #119) of 17 smokers observed with lighters in their rooms. The unsafe practice of allowing four of 17 residents who smoke to store unsecure ignition sources such as lighters in their rooms created a significant fire hazard from accidental ignition. […]

• Immediate jeopardy, isolatedF835Mar 6, 2026

  Based on observation, record review, residents and staff interviews, the facility administration failed to provide effective oversight and failed to take appropriate actions to protect residents' safety from foreseeable and avoidable incidents from unsafe smoking practices and unsafe storage of ignition devices. This failure created an environment that placed four (Residents #37, #67, #118 and #119) of 17 resident smokers at a likelihood of serious injury, impairment or death from an accidental fire and resulted in the determination of Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF926Mar 6, 2026

  Based on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's Resident Smoking Supervised and Unsupervised policy to ensure safe smoking practices for 4 (Residents #37, #67, #118 and #119) of 4 sampled residents reviewed for safe smoking out of 17 total smokers in the facility.The facility failure to enforce the smoking policy that clearly addressed the safe storage of ignition devices by allowing residents to keep lighters/ignition devices unsecured in their rooms created an avoidable fire safety risk, placing four of 17 resident smokers at a likelihood for serious harm, injury or death. These concerns resulted in the determination of immediate jeopardy. […]

• Immediate jeopardy, isolatedF600Aug 25, 2023

  Based on observations, record review, review of policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from neglect, in that the facility failed to ensure staff who use mechanical lifts to transfer residents were trained, and competent to safely use the lifts. Resident #1 was dependent on staff for transfer and required the use of a mechanical lift. On 8/12/23 Resident #1 fell from the full body mechanical lift during transfer. Resident #1 was hospitalized and suffered spinal and pelvic fractures. There was no documentation the staff who transferred Resident #1 were trained and competent to safely use the mechanical lift. […]