AdviniaCare Naples: Dementia Patients Escape Facility - FL
It was the third time in four months that a cognitively impaired resident had escaped AdviniaCare at Naples and been found wandering unsupervised outside the facility. Federal inspectors determined the pattern created immediate jeopardy to resident safety.
The first incident occurred December 9 at 2:15 p.m., when Resident #1 walked out wearing a wander alarm bracelet that triggered the door alarm. Staff ignored the alarm. Two minutes later, another employee on her break discovered the resident wandering in the parking lot and brought him back inside.
The facility's corrective action plan promised an "education sheet" instructing staff to "check everyone leaving, beware of tailgaters" when door alarms sound.
On February 24 at 4:30 p.m., Resident #2 slipped out while wearing a wander alert bracelet. Staff had no idea he was missing. A friend arriving for a visit found the resident wandering in the parking lot and alerted the Director of Nursing, who retrieved him.
The former Executive Director sent an email the next day to 11 managers about the "elopement with a skilled resident." The message noted the resident was on a "roam alert program" and had been placed on one-to-one supervision. It concluded: "All will be working on today to ensure we have a great credible evidence binder for the State."
The facility's investigation never determined how Resident #2 escaped despite the wander bracelet. The current Executive Director's analysis simply noted the doors "were checked and were working appropriately."
Five weeks later, Resident #3 walked out undetected around 6:40 p.m. on March 29. Only the departing staff member's chance observation prevented a longer disappearance.
When inspectors tested the alarm system April 15, they discovered critical failures. The Maintenance Director triggered a wander alarm at the end of the 150 hall using a bracelet. The audible alarm could not be heard at the nurse's station 125 feet away. No staff responded.
He then activated the wander alarm at the facility's front entrance. The door locked but produced no audible alert to notify staff that someone with a wander bracelet was trying to exit.
"Any time we have an elopement, it is through the front door," the Maintenance Director told inspectors. The front door "takes a long time to close and has no audible alarm," creating potential for residents to escape. "The problem with the doors has been going on for quite some time."
After the March elopement, the Executive Director had asked him to get quotes for locks requiring staff to physically push a button at the nurse's station to open doors. A company had visited the previous week but hadn't submitted pricing yet.
The Administrator and Director of Nursing revealed they were unaware of the door system's failures. Both said they didn't know the entry doors lacked audible alarms. They were unaware that residents with wander bracelets could follow someone through already-opened doors without triggering any alert.
"I had only been at the facility since the second week of March and was figuring things out," the Administrator explained.
She had previously worked at a facility where doors remained locked at all times. At AdviniaCare, doors were only secured from 8 p.m. to 8 a.m. She believed residents were safe because wander bracelets would lock doors when they approached.
When asked about cognitively impaired residents following others through open doors, she responded: "You can't guarantee people wouldn't get out, they could open a window, anything to get out. You can't guarantee anything 100%. You are dealing with systems, you are dealing with people."
Two residents remained at risk for unsafe wandering and wore wander alert bracelets at the time of inspection.
The facility's elopement prevention policy required functional alarm systems for exits and quarterly elopement drills on each shift. Staff training materials from January 2024 stated that front doors should lock when residents with "wonder guard" approach, and hallway doors should beep when wander alerts come near.
The materials noted: "These doors will also alarm when door opened, if alarm goes off must check outside to see if a resident has exited the facility." No attendance records documented how many staff received this training.
Inspectors found the facility's Quality Assurance and Performance Improvement program failed to identify the systemic problems enabling repeated elopements. Despite three incidents in four months, management had not implemented effective corrective measures to prevent cognitively impaired residents from leaving unsupervised.
The inspection report noted that escaped residents could cross the nearby busy four or six-lane highway, be struck by vehicles, or fall while walking on uneven and overgrown grounds behind the facility. Such incidents could result in serious injury or death.
Federal inspectors classified the violations as immediate jeopardy, indicating conditions likely to cause serious harm, injury or death to residents. The Administrator was notified of the determination April 17 at 9:12 a.m.
The Executive Director's job description stated he was "totally responsible for management" and must "take ownership for the safety of the residents." The Director of Nursing was required to "ensure adequate staffing patterns" and oversee nursing operations to meet residents' physical and psychosocial needs.
All three escaped residents had severe cognitive impairment, making them unable to protect themselves from harm if they successfully left the facility unsupervised and unnoticed.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ADVINIACARE AT NAPLES in NAPLES, FL was cited for violations during a health inspection on April 18, 2025.
Federal inspectors determined the pattern created immediate jeopardy to resident safety.
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.