Woodside Health: Dementia Patient Escaped to Gas Station - FL
Resident #53 had been admitted to Woodside Health and Rehabilitation Center on April 26 from a hospital where doctors documented "active delirium and agitation" and suspected Alzheimer's dementia. The hospital physician wrote that she would "need constant supervision from now on."
On May 1, her attending physician signed a statement declaring that Resident #53 no longer had the capacity to make health care decisions for herself. The next day, she disappeared.
Licensed Practical Nurse Staff A told inspectors she was assigned to Resident #53 on May 2 and "usually kept a close eye on Resident #53, as she liked to wander." While caring for a different resident, Staff A noticed Resident #53 was gone. Staff searched the building before finding her at the gas station across the street.
But administrators decided the incident wasn't an escape at all.
The interim Director of Nursing told inspectors they conducted a "soft investigation" and determined it was a "near miss," not an elopement. She said Resident #53 scored 13 on a mental status test, "indicative of intact cognition," and could describe how she left the facility.
The Administrator said they did a root cause analysis and concluded it wasn't an elopement because the resident "was cognitively intact, knew where she was going, and had not been incapacitated." He said Resident #53 "simply failed to follow the facility's leave of absence policy. She wanted to go to the store per her normal routine."
Neither administrator knew about the incapacity statement signed by the physician the day before the escape.
When inspectors showed the Administrator the May 1 incapacity declaration, he said: "Had I known Resident #53 was incapacitated, I would have considered the incident an elopement without a doubt."
The interim Director of Nursing made the same admission: "She said definitely the incident would have been considered an elopement and would have been reported for sure."
The facility's own elopement policy defined an elopement as "a situation in which an incapacitated resident leaves the facility grounds or a safe area without the facility's knowledge and supervision." The policy required staff to assess each incapacitated resident for wandering risk and implement safety strategies.
The incapacity statement wasn't uploaded to Resident #53's medical chart until May 8, after she had already been discharged from the facility.
Staff never documented the wandering incident in the resident's medical record. LPN Staff A told inspectors: "It was all just verbal."
The facility's security systems were failing when inspectors arrived two weeks later.
On May 16, the Director of Nursing demonstrated the wander alert bracelets for six residents identified as elopement risks. Resident #24's bracelet wasn't working at all. The light that should verify proper function didn't come on, meaning the bracelet wouldn't trigger door alarms. The Director of Nursing said she would place the resident on one-to-one supervision until the bracelet could be replaced.
Resident #59's bracelet showed a red light, indicating a low battery that needed immediate replacement.
The maintenance director tested three exit doors with inspectors present. Two Heritage Hall egress doors made beeping sounds when pressed but failed to sound loud alarms when fully opened. A third door in the dining room that led to a screened porch was supposed to be magnetically locked. Instead, it pushed open easily without any alarm.
"The door should not be able to be opened," the maintenance director told inspectors. "My guy was out here power washing earlier."
The maintenance director instructed his assistant to fix both malfunctioning Heritage Hall doors during the inspection.
LPN Staff B, who was on duty during the May 2 incident, told inspectors she heard a door alarm go off near rooms in the 300 hall. She said it was caused by a visually impaired resident who had pushed on the door, so she shut the alarm off. Emergency Medical Services arrived 20 to 30 minutes later asking if the facility had a missing resident.
Only then did staff realize Resident #53 was gone.
The facility's elopement policy required staff to announce "Code Orange" immediately when an incapacitated resident went missing, note the time of discovery, conduct head counts, and check surrounding areas outside. Staff called EMS showed up before anyone had announced the code or begun searching for the missing resident.
The Administrator said they conducted elopement drills the day after the incident and retrained "at least 75%" of staff on elopement policy. The incident was discussed in a Quality Assurance meeting on May 9, but no performance improvement plan was implemented since administrators didn't consider it an elopement.
The facility had no current performance improvement plan related to elopement prevention when inspectors reviewed the quality assurance program on May 16.
The Administrator and interim Director of Nursing both signed job descriptions acknowledging their responsibility for resident safety and regulatory compliance. The Administrator's job description required him to "ensure adherence to the Patient's Rights" and "operate the facility in accordance with federal, state and local regulations."
The Director of Nursing's job description required her to "ensure residents' safety in accordance with resident safety program" and "ensure compliance with government and accrediting agency standards."
Federal inspectors initiated a neglect investigation on May 12 related to Resident #53's elopement. The investigation confirmed that all exit doors were checked for proper functioning, but found the incapacity statement had not been uploaded to the resident's chart until after her discharge.
During the May 2 incident, staff members went to the gas station, recognized Resident #53, and brought her back to the facility. The Administrator and Director of Nursing were notified and came to the facility after the resident had already been retrieved.
The facility updated its elopement policy on January 1, 2025, but the interim Director of Nursing told inspectors on May 14 that she "did not realize the policy had been updated." The revised policy still focused only on incapacitated residents and required assessment for wandering upon admission and whenever elopement attempts or new wandering behaviors were observed.
As inspectors concluded their review on May 16, administrators had failed to conduct a thorough investigation of the elopement incident or implement effective processes to maintain safety for cognitively impaired residents. The broken door alarms, malfunctioning wander alert bracelets, and failure to recognize an incapacitated resident's escape as an elopement left other vulnerable residents at risk of similar incidents.
Resident #53 had walked across a street to reach the gas station, exposing herself to traffic and other dangers that the facility's policies were designed to prevent.
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
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
WOODSIDE HEALTH AND REHABILITATION CENTER in NAPLES, FL was cited for violations during a health inspection on May 16, 2025.
Staff searched the building before finding her at the gas station across the street.
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.