The woman, identified as Resident 53, had been admitted six days earlier from a hospital where physicians documented "active delirium and agitation" and suspected Alzheimer's dementia. Her attending physician signed a statement on May 1 declaring she "no longer had the capacity to make knowing health care decisions for herself."
The next day, Licensed Practical Nurse Staff A was caring for other residents when she realized the woman had vanished.
"I usually kept a close eye on Resident 53, as she liked to wander," Staff A told inspectors. "She said they looked for the resident all around the building. She said Resident 53 got out of the building and was eventually located at the gas station across the street."
The escape happened despite door alarms sounding. LPN Staff B heard the alarm system activate near rooms 331 and 332 around the time the woman left. But Staff B shut off the alarm, assuming it was triggered by a visually impaired resident who "had pushed on the door causing it to alarm."
Emergency Medical Services arrived 20 to 30 minutes later asking if the facility had a missing resident. Only then did staff realize the woman was gone.
Administrator and Director of Nursing staff retrieved the patient from the gas station across Lakewood Boulevard, a busy Naples thoroughfare.
But facility leadership refused to classify the incident as an elopement. Instead, they called it a "near miss."
The interim Director of Nursing told inspectors she evaluated the woman's mental status after her return. The patient scored 13 on a cognitive assessment, which the DON interpreted as "intact cognition."
"They did not consider the incident an elopement but a near miss," the DON explained. "Resident 53 knew what she was doing and was able to describe that Friday and again the next day on Saturday how she left the facility."
The facility's investigation concluded the incident didn't meet elopement criteria because the resident could demonstrate how she left and "was taught as a child to look both ways to cross the street."
Administrator told inspectors the woman "simply failed to follow the facility's leave of absence policy. She wanted to go to the store per her normal routine."
Neither the Administrator nor the interim DON knew about the incapacity statement signed the day before the escape.
"Had I known Resident 53 was incapacitated, I would have considered the incident an elopement without a doubt," the Administrator admitted.
The DON echoed this: "Definitely the incident would have been considered an elopement and would have been reported for sure."
The incapacity statement wasn't uploaded to the patient's electronic chart until May 8, after she had already been discharged.
Woodside's elopement policy defines the violation precisely: "A situation in which an incapacitated resident leaves the facility grounds or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement."
The policy requires staff to assess each incapacitated resident for wandering risk and implement safety interventions. When an incapacitated resident goes missing, staff must "initiate the elopement/missing resident emergency procedure" and "announce Code Orange."
None of this happened. Staff A told inspectors the wandering behavior and escape incident lacked any documentation. "It was all just verbal," she said.
The mishandling extended beyond this single case. During the May 16 inspection, federal surveyors discovered multiple safety system failures that left other vulnerable residents at risk.
Resident 24, identified as an elopement risk, wore a wander alert bracelet that wasn't working. When the DON tested it, "the light verifying the wander alert bracelet was functioning properly did not come on, indicating the wander alert bracelet would not set off the alarm if the resident went through a door equipped with a wander alert system."
Resident 59's wander alert bracelet showed a red light, meaning the battery was low and needed immediate replacement.
The door alarm systems proved equally unreliable. When maintenance staff tested the Heritage Hall East egress door, it made only a beeping sound when the bar was pressed. The door opened fully without triggering the loud alarm designed to alert staff.
The same malfunction occurred with the Heritage Hall West egress door.
A third exit door in the dining room, which was supposed to be magnetically locked, opened easily when pushed. The Maintenance Director told inspectors, "The door should not be able to be opened."
He blamed recent power washing for the malfunction, but couldn't explain why the failure went undetected during daily safety checks the facility claimed to conduct.
The Administrator acknowledged conducting elopement drills and retraining staff after the May 2 incident, claiming "at least 75% of the staff were reeducated on the elopement policy."
But no performance improvement plan was implemented because leadership maintained their position that no actual elopement had occurred.
The facility discussed the incident during a Quality Assurance meeting on May 9, but took no corrective action beyond the staff training.
Federal inspectors found the facility's administration "failed to have documentation of a thorough investigation of Resident 53's elopement incident and effective use of resources to ensure processes were implemented to maintain the safety of cognitively impaired and confused residents."
The violation received an "immediate jeopardy" rating, the most serious level of harm in federal nursing home oversight.
Resident 53's hospital discharge summary had warned that her delirium and agitation required constant supervision. "I do not think this patient can go back to her independent living facility," her physician wrote. "She will need constant supervision from now on."
Instead, she walked unnoticed through a back door, crossed a busy street, and spent an unknown amount of time alone at a gas station while staff assumed door alarms were false alerts.
The DON promised to place Resident 24 on one-to-one supervision until her broken wander alert bracelet could be replaced. Maintenance staff were instructed to repair the malfunctioning door alarms.
But for Resident 53, the fixes came too late. She had already been discharged by the time the facility's neglect investigation began on May 12, ten days after she walked out the door they claimed she never really left.
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.
Additional Resources
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