Resident #53 had been at the facility for six days when she disappeared on May 2, 2025. Emergency medical services found her at the gas station approximately 0.1 mile away and spent 20 to 30 minutes trying to identify which facility she belonged to before staff discovered she was gone.
The 83-year-old woman had been transferred from a hospital on April 26 with active delirium and agitation. Her discharge summary warned that she would need "constant supervision from now on" and could not return to independent living. Hospital doctors suspected Alzheimer's dementia.
Despite these warnings, facility staff marked "No" on her elopement risk evaluation for cognitive impairment, independent ambulation ability, and exit-seeking behavior. They determined she was not an elopement risk but noted she needed "increased staff observation."
Her behavior had been escalating since admission. On April 27, staff found her sitting on the floor next to her bed with her oxygen off, yelling "You're trying to murder me, you're in love with my husband, you're having an affair with him."
Two days later at 1:27 a.m., she was standing naked in the hallway calling a nurse "a witch." At 2:30 a.m., she sat on the floor trying to hit and kick staff. She kicked and scratched a nurse.
Licensed Practical Nurse Staff A was assigned to the resident on May 2. She told inspectors she "usually kept a close eye on Resident #53, as she liked to wander" and that the woman had "extreme behaviors including not staying in one spot."
But when Staff A was caring for a different resident, she noticed the woman was gone.
"They looked for the resident all around the building," according to the inspection report. The resident later explained "how she went out the back door and pushed the egress bar for 15 seconds to be let out."
The door alarm did sound. LPN Staff B heard it and initially thought it was a visually impaired resident who had accidentally triggered it. She shut off the alarm.
Twenty to thirty minutes later, emergency medical services arrived asking if the facility had a missing resident. They had found someone at the gas station but didn't recognize the name the person gave them. Staff initially couldn't locate anyone with that last name in their computer system.
Only when Staff A went down the hall looking for Resident #53 did they realize she was missing. Staff went to the gas station, recognized her, and brought her back.
The woman had crossed a busy four-lane road and reached an eight-lane highway to get to the gas station.
When she returned, the interim Director of Nursing tested her cognition. The resident scored 13 on the Brief Interview for Mental Status, indicating intact cognition. But just one day earlier, a psychiatrist had documented that she scored a 5 on the same test, indicating "severely impaired cognition."
The psychiatrist had found her "difficult to redirect" with symptoms occurring daily and causing severe distress. He noted she had "severe cognitive impairment" and was "unstable."
The facility's response puzzled inspectors. Administrator and nursing leadership called it a "near miss," not an elopement. They conducted what they called a "soft investigation."
"Resident #53 knew what she was doing and was able to describe it that Friday and again the next day on Saturday," the interim Director of Nursing told inspectors.
The Administrator said they did a "reenactment" with the resident. "She took him to the exit door and was able to demonstrate how she opened the door. She was able to do it again the next day."
Because they didn't consider it an elopement, no performance improvement plan was implemented, even though the incident was discussed in a Quality Assurance meeting on May 9.
The facility's own policy defines elopement as "a situation in which an incapacitated resident leaves the facility grounds or a safe area without the facility's knowledge and supervision."
Staff acknowledged the resident's wandering behaviors were never documented in her clinical record. "It was all just verbal," LPN Staff A told inspectors when asked why there was no documentation of individualized interventions to prevent elopement.
The woman's son told inspectors the elopement "should never have happened, absolutely not." He said his mother "has always had wandering behaviors" and had exhibited them when living with him.
After the incident, the facility told him they could no longer provide services for his mother. "It's been an ongoing battle for two to three years. She did not have a place to go due to her behaviors," he said.
Inspectors found a second medication safety violation involving a different resident who had been keeping bottles of melatonin, glucosamine supplements, and laxatives at her bedside for two years without staff knowledge.
Resident #48 told inspectors "the nurses don't know that I have them." She shared a room with a woman who has Alzheimer's disease and "sometimes takes her belongings."
The medications remained unsecured on her bedside table even when both residents were out of the room. Licensed Practical Nurse Staff D, who had cared for the resident since July, said she had never noticed the medications.
Federal inspectors determined the elopement incident created "immediate jeopardy" to resident health and safety. They found the facility administration failed to recognize the neglect and implement appropriate action to prevent similar incidents with other cognitively impaired residents.
The inspection report notes that residents who exit without supervision could "cross the nearby busy four lane road or nearby eight lane highway, get hit by a car, or sustain a fall resulting in serious injury from walking the uneven ground around the facility."
Woodside Health and Rehabilitation Center is located at 3601 Lakewood Boulevard in Naples.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodside Health and Rehabilitation Center from 2025-05-16 including all violations, facility responses, and corrective action plans.
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