AdvinaCare at Naples: Elopement Drill Falsified - FL
The MDS Coordinator had no idea what anyone was talking about.
Federal inspectors were at the facility that same day. They were there because of an Immediate Jeopardy citation, the most serious classification available under federal nursing home oversight, one that signals a direct and serious threat to resident health or safety. The citation involved elopement, the term the industry uses when a resident wanders or walks away from a facility without authorization. At some point that morning, a resident had been found missing. Staff searched the unit, then the facility, then the grounds. They found the resident. The search was called off. The time the resident was found was recorded as 8:55 a.m.
What happened next is where the record starts to fall apart.
To address the Immediate Jeopardy finding, the facility was required to demonstrate that staff had been educated on elopement procedures, that they understood what to do, and that they were prepared to respond. An elopement drill was conducted, or at least that is what the sign-in sheet showed. Seventeen names. The DON. The MDS Coordinator, identified in inspection records as Staff H.
At 12:45 p.m. that afternoon, inspectors interviewed Staff H. She said she came to work at 6:00 a.m. She said she did not hear any announcement for an elopement drill. She said she did not participate in an elopement drill. What she did experience was a visit from the Maintenance Director, who stopped by her office and asked her a question. "If this happens," he said, meaning an elopement, "what would you do, basically."
That was it. That was the drill.
Twenty minutes later, at 1:05 p.m., inspectors spoke with the Maintenance Director, who confirmed he had conducted the elopement drill for April 18. He explained his method. Normally, he said, he would gather staff together. This time he went person to person, moving through the building, asking each staff member individually what they would do in case of an elopement and what they would look for. He said he announced the drill, but not in a group setting. He said he had educated the laundry staff and considered that education to count as a drill.
The Maintenance Director, by his own account, turned a required emergency preparedness drill into a series of informal one-on-one conversations, logged them as a completed facility-wide exercise, and put 17 names on a sign-in sheet.
At 1:45 p.m., inspectors met with both the DON and the Administrator to discuss the facility's plan for removing the Immediate Jeopardy designation. The Administrator said she did not know the Maintenance Director had not conducted the drill in the way it was supposed to be conducted. She said she would reeducate him. She also confirmed, on the record, that the staff education that had been provided was generalized and not specific to each department.
Elopement is among the most dangerous things that can happen in a nursing home. Residents who wander are often cognitively impaired, unable to ask for help or explain who they are or where they came from. In warm climates like southwest Florida, the window between a resident leaving a facility undetected and a medical emergency is short. The purpose of elopement drills is not bureaucratic. It is to make sure that every person working in a building, from the nursing staff to the laundry room, knows exactly what to do the moment someone is unaccounted for: who to call, where to look, how fast to move.
The facility had a resident go missing that morning. Staff found the person. The outcome, in that instance, was recorded as good. But the response to the Immediate Jeopardy finding, the part that was supposed to demonstrate the facility had learned something and corrected something, rested on a sign-in sheet that did not reflect what actually happened.
Staff H's name was on that sheet. She had not participated in a drill. She had answered a question in her office.
The Administrator's statement to inspectors is worth sitting with. She said she did not know the Maintenance Director had done it wrong. She said she would reeducate him. She confirmed the education was not department-specific. None of that is a defense of the sign-in sheet. Someone put Staff H's name on a document certifying her participation in a drill she did not attend. The Administrator did not explain that. Inspectors did not record an explanation for it.
What the inspection record shows is a facility that, on the same day federal inspectors were present and reviewing an Immediate Jeopardy finding, produced documentation of a corrective action that one of the named participants immediately contradicted. The MDS Coordinator did not hedge. She did not say she was uncertain or that she might have missed an announcement. She said she did not hear one. She said she did not participate.
The Maintenance Director, for his part, seemed to believe that what he had done was sufficient. He went person to person. He asked questions. He talked to the laundry staff. He considered it done.
The Administrator said she would reeducate him.
Somewhere in that building, earlier that morning, a resident had been found missing at 8:55 a.m. The search had been called off when the resident was located. The inspection form noted the staff performance result was good. That part, at least, appears to be true.
What came after, the documentation, the sign-in sheet, the 17 names, the drill that was not a drill, is a different record entirely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adviniacare At Naples from 2025-04-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 27, 2026 · Our methodology
ADVINIACARE AT NAPLES in NAPLES, FL was cited for violations during a health inspection on April 18, 2025.
The MDS Coordinator had no idea what anyone was talking about.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.