Harborchase Of Naples

F-F835.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 105995 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105995 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan reviewed 2/7/21 revealed, (Company name) shall ensure that the Governing Body, Administration, Medical Director, Director Level of Harm - Immediate of Nursing, clinical and non-clinical staff demonstrate a consistent endeavor to deliver safe, effective, optimal jeopardy to resident health or resident care and services in an environment of minimal risk . The organizational program, established by safety the Medical Director and Director of Nursing and Interdisciplinary Performance Improvement Committee . shall have the responsibility for monitoring every aspect of resident care and services (including contracted Residents Affected - Some services), from the time the resident enters the facility through diagnosis, treatment, recovery and discharge

in order to identify and resolve any breakdowns that may result in suboptimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes . The committee shall identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revision to the action plan . Track the status of identified problems and action plans to assure improvement or problem resolution .

On 4/14/25 at 9:24 a.m., in an interview the Director of Nursing (DON) said she was aware of the three resident elopements and the facility had not yet developed a Performance Improvement Plan (PIP) to address the elopements. They obtained orders and updated the care plans for the residents involved.

On 4/15/25 at 10:05 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) to review the incident investigations related to Residents #1, #2, and #3's unsafe wandering and elopement, root cause analysis, and appropriate systemic actions to prevent recurrence.

The Administrator said she started employment at the facility the second week of March and was trying to figure out what was going on here. She said she could not comment on Residents #1's elopement as she had not started employment at the facility. She verified she was aware of Resident #2's elopement and completed the investigation.

The Administrator and DON verified Resident #3 eloped on 3/29/25 and was found unsupervised outside the facility.

The Administrator said they did not conduct elopement drills after Resident #3's elopement but have been doing staff education. She said she's had only one QAPI meeting since she started employment at the facility

the second week of March and she, was trying to figure out what is going on here. She said she had not developed a PIP as of yet to address the multiple incidents of residents' elopements. She said she thought

the doors should be shutting if someone with a wander alert bracelet was there. She said she was not aware that someone with a wander alert bracelet could walk out with visitors. She verified the nurse's station was often empty and agreed cognitively impaired residents who require supervision could just get out.

On 4/15/25 at 11:50 a.m., in an interview the DON said she was not present the day Resident #3 was found outside. Based on staff statements obtained the resident did not have a wander alert bracelet and was found sitting by the front door. She said she believed Resident #3 propelled herself out of the front door looking for her brother. The DON said she assumes no one was at the nurse's station at the time the resident eloped.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 105995 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105995 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 On 4/16/25 at 3:25 p.m., in an interview the Administrator said she was the Risk Manager for the facility. The last Quality Assurance Meeting was held on 3/26/25 to present the February 2025 data. They discussed Level of Harm - Immediate Resident #2's elopement and talked a little about the scenario and the two residents with wander alert jeopardy to resident health or bracelets. The Administrator said she believes Resident #2 was trailing behind people that were leaving. She safety immediately placed the resident on one to one supervision. The wander alert books were reviewed, the bracelets checked and the care plans were updated. She held a town hall meeting with staff around the time Residents Affected - Some of the elopement and discussed the elopement. She said they did not do any elopement drills. She usually starts with education but scheduled an elopement drill for this week on Thursday. She said Resident #3 was not an elopement risk and did not have a wander alert bracelet. They applied one after she eloped. She said

after the third elopement, the Maintenance Director and her started talking about what could be done about

the door and started calling door companies. The Medical Director was aware of the elopements. He attended the last QAPI meeting and had no comments. She said securing the hallway connecting the skilled nursing facility to the Assisted Living Facility was not considered since she's been here. She verified the front door of the facility open automatically and is not supervised.

The Administrator said nothing was 100% full proof that someone can't get out, crazy things happen. She said she felt the residents were safe because the wander alert bracelets would lock the door down. She said again, Nothing is 100% full proof. You are dealing with systems and people.

The Administrator verified the elopement investigations failed to identify the lack of audible alarm of the wander alert system on the exit doors to notify staff if a confused resident with a wander alert bracelet followed visitors through the opened doors. The investigations did not identify the lack of monitoring of exit doors to prevent cognitively impaired residents from exiting the facility unsupervised.

Review of the facility's approved Immediate Jeopardy removal plan revealed as part of their immediate corrective actions, the facility educated 35 of 42 staff on residents at risk for elopement and elopement interventions. Staff was educated on new process for doors to be locked and someone will have to allow entrance and exit of residents, families and guests. The staff member must observe doors until they are fully closed.

Staff educated on elopement procedures including verifying all residents are accounted for prior to shutting alarm off. Staff was educated on all residents who are at risk for elopement along with elopement interventions, behavioral sign and symptoms of elopement and elopement interventions.

Review of the education program agenda dated 4/17/25 revealed the content of the education was, Know the process of elopement. If you have a resident who voiced they want to leave the facility, please notify a supervisor. If you hear an alarm, make sure there is nobody outside and make sure you notify your nurse or your supervisor. Know elopement behavioral sign and symptoms of elopement and interventions to take when that is occurring. When you have someone actively experienced [sic] exit seeking behavior. As the nurse, contact your physician right away and your DON and administrator to make sure the resident is safe at all cost by etc. [sic] . placing the resident on 1:1 or [wander alert bracelet] per physician orders. Make sure to verify all residents are accounted prior to shutting alarm off.

The sign-in sheet noted 30 staff members attended the in-service, including dietary, housekeeping, medical records and laundry staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 105995 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105995 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 On 4/18/25 at 12:02 p.m., in an interview Licensed Practical Nurse Staff G said she started employment at

the facility a week ago. She came in to be educated on the elopement process. She said the DON told her if Level of Harm - Immediate she saw a resident outside, secure the resident and do an assessment. The DON did not talk to her about jeopardy to resident health or elopement prevention but she overheard the DON speaking to someone else about elopement prevention. safety

The immediate actions in the facility's approved removal plan also included, Elopement drills will be done on Residents Affected - Some all shifts. Elopement drills were conducted on 4/15/25, 4/16/25, 4/17/25 and 4/18/25.

Review of the Elopement. Post-Elopement Drill Checklist dated 4/18/25 revealed the Maintenance Director completed the form. He documented the resident missing time was 8:45 a.m., and the resident found time was 8:55 a.m. The form noted staff verified the resident was not signed out, checked the unit, a full search of

the facility and grounds was implemented. The search was called off when the resident was found. The staff performance result was good and staff did respond in accordance with established procedures.

Review of the sign-in sheet for the elopement drill of 4/18/25 revealed 17 staff members responded to the drill, including the DON and Minimum Data Set (MDS) Coordinator Staff H.

On 4/18/25 at 12:45 p.m., in an interview MDS Coordinator Staff H said she came to work at 6:00 a.m. She did not hear an announcement for an elopement drill and did not participate in an elopement drill. Staff H said the Maintenance Director came to her office and asked her questions. He asked, If this happens (elopement), what would you do basically.

On 4/18/25 at 1:05 p.m., in an interview the Maintenance Director verified he completed the elopement drill of 4/18/25. The Maintenance Director said normally he would gather staff but this time he went person to person and asked each staff member individually what they would do in case of an elopement, and what they would look for. He announced an elopement drill but not in a group setting. He said he even educated the laundry girls and considered the education an elopement drill.

On 4/18/25 at 1:45 p.m., an interview was held with the DON and the Administrator to discuss implementation of the facility's Immediate Jeopardy removal plan. The Administrator said she did not know

the Maintenance Director did not conduct the elopement drill and would reeducate him.

The Administrator verified the staff education provided was generalized and not specific to each department.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 105995

F-F867.

Review of the Executive Director's job description signed on 3/3/25 revealed, The Executive Director is totally responsible for the management of the . Skilled Nursing Facility . Also, ensures high quality resident care services . Oversees and monitors nursing services . to ensure high quality nursing delivery systems . Implement quality assurance programs for all departments . Directs community safety . monitors adherence to safety rules and regulations and takes remedial action when necessary . The ability to take ownership for .

the safety of the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 105995 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105995 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Review of the Director of Nursing job description signed on 1/7/25 revealed, The Director of Nursing manages and directs the day-to-day functions of the Nursing Department in accordance with established Level of Harm - Immediate policies, procedures, and practices that comply with federal, state, and local regulations . In addition, the jeopardy to resident health or Director of Nursing ensures adequate staffing patterns, and that staff are qualified and trained. Essential safety Functions . Provide basin nursing care to patients . that includes actions that meet psychosocial needs and physical needs. Oversees the management and daily operations of the nursing department . Ensures that Residents Affected - Some each patient's needs are assessed and that a treatment plan is developed for nursing care .

Review of the facility policy titled, Elopement Prevention with a last revised date of 10/2022 revealed, Elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way . The physical plant is secured to minimize the risk of elopement such as: a. functional alarm systems for egresses and stairwells . Staff should be educated on the elopement policy on hire, annually and as needed per facility events. Facility should conduct and maintain tracking an elopement drill at least quarterly on each shift. Identifying staff knowledge of policy and need for further training/education .

On 4/15/25, review of the facility's incident investigations for December 2024 through March 2025 revealed three incidents of elopement, which placed the affected residents with severe cognitive impairment at a likelihood of serious harm, serious injury or death.

On 12/9/24 at 2:15 p.m., staff did not respond appropriately to the door alarm when Resident #1 who wore a wander alarm bracelet, exited the facility and set off the alarm. On 12/9/24 at approximately 2:17 p.m., a staff member who was outside on her break found the resident wandering in the parking lot unsupervised and returned him to the facility.

As part of their investigations the facility provided a Four Step Plan of Correction to Prevent Recurrence. Under, What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? was the notation, Education sheet if you hear alarm, check everyone leaving, beware of tailgaters.

The facility also provided an in-service dated 01/30/24 which included elopement and read, Elopement. When Code Orange is called all employees should assist with this code. A count will be made for all residents in facility . Front doors will lock when resident with wonder guard [sic] approaches door. The doors end of 170 hallway and 160 hallway will beep when a [wander alert] approaches door. These doors will also alarm when door opened, if alarm goes off must check outside to see if a resident has exited the facility. The door leading to the time clock is also alarmed and will beep and lock if a [wander alert] is close by . There was no sign-in sheet to determine how many staff members attended the in-service.

On 2/24/25 at 4:30 p.m., staff did not adequately supervise Resident #2 who wore a wander alert bracelet.

The facility staff was not aware of the resident's exit. A friend coming to visit found Resident #2 wandering in

the parking lot unsupervised. He notified the DON who took the resident back inside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 105995 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105995 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 On 2/25/25 the former Executive Director documented in an email to 11 managers titled, AD HOC QAPI (Unplanned Quality Assurance and Performance Improvement), Team, we had an elopement with a skilled Level of Harm - Immediate resident last night. Friend/Family driving to center and saw him in the parking lot. Resident on roam alert jeopardy to resident health or program, one to one placed, MD (physician) and Family Made Aware, Skin Check, Statements, Education, safety Post Elopement Drills, Like residents. All will be working on today to ensure we have a great credible evidence binder for the State. Residents Affected - Some

On 3/10/25 the current Executive Director documented an analysis of the incident and noted the wander alert bracelet the resident had on and the doors were checked and were working appropriately.

The investigation did not include how Resident #2 was able to exit the facility without staff knowledge despite

the wander alarm bracelet. The facility placed the resident on one to one supervision but did not include appropriate systemic measures to ensure residents' safety and prevent other cognitively impaired residents from exiting the facility without staff knowledge or supervision.

On 3/29/25 at approximately 6:40 p.m., staff did not adequately supervise Resident #3 who was mobile and had severe cognitive impairment. Resident #3 exited the facility without staff knowledge. On 3/29/25 at approximately 7:05 p.m., a staff member leaving work observed the resident outside, unsupervised through her rearview mirror. She notified the nurse on duty who came and took the resident back inside.

The facility's investigation included corrective actions which included an elopement evaluation for Resident #3. The resident was found at elopement risk and a wander alert bracelet was placed to the resident's right ankle.

On 4/15/25 at 9:43 a.m., the Maintenance Director used a wander alert bracelet to set off the wander alarm of the door at the end of the 150 hall. The audible alarm could not be heard at the nurse's station located approximately 125 feet away. No staff responded to the wander alarm.

The Maintenance Director then set off the wander alarm of the entrance door of the facility. The door locked but had no audible alarm to alert staff if a resident with a wander alarm bracelet approaches the exit door.

On 4/15/25 at approximately 9:55 a.m., in an interview the Maintenance Director said when opened, the front door takes a long time to close and has no audible alarm. He said there was a potential for a resident to leave. The Maintenance Director said, Any time we have an elopement, it is through the front door. The ALF door also locks but does not alarm. The Maintenance Director said the problem with the doors has been going on for quite some time. The Maintenance Director said after the last elopement the Executive Director (Administrator) told him to get quotes for a lock on the doors that would require someone to physically push a button behind the nurse's station to open the door. The Maintenance Director said a company came out last week but had not sent a quote yet.

On 4/15/25 at 10:05 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON) to discuss residents' safety and elopement prevention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 105995 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105995 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Both the Administrator and DON said they did not know the entry doors of the skilled nursing facility and the ALF did not alarm. They both said they were not aware that a resident with a wander alarm bracelet could Level of Harm - Immediate freely follow someone out already opened doors with no audible alert to staff. The Administrator said she had jeopardy to resident health or only been at the facility since the second week of March and was, figuring things out. safety

On 4/16/25 at 3:40 p.m., in an interview the Administrator said at her previous facility the doors were locked Residents Affected - Some at all times, that was why she had a discussion with the Maintenance Director about calling a door company to see what could be done about the front door. She said other than that, nothing else was changed with the doors. She said the doors were locked down from 8:00 p.m., to 8:00 a.m., and she felt the residents were safe because the wander alarm bracelet would lock the door down if they approached it.

When asked about a cognitively impaired person following someone out an already opened door, she said, 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.

The Administrator verified two current residents were at risk for unsafe wandering and elopement at the facility and had a wander alarm bracelet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 105995 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105995 B. Wing 04/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Immediate jeopardy to resident health or 37256 safety Based on observation, record review and interview, the facility failed to thoroughly investigate elopement Residents Affected - Some incidents for 3 (Residents #1, #2, and #3) of 3 cognitively impaired residents reviewed for elopement and failed to implement appropriate systemic corrective actions to prevent further incidents of unsafe wandering and elopement of mobile and confused residents.

On 12/9/24 at 2:15 p.m., Resident #1 who had severe cognitive impairment and wore a wander alert bracelet exited the facility, setting off the door alarm. Staff did not appropriately respond to the alarm. A staff member who was outside on her break found the resident wandering unsupervised in the parking lot and brought him back.

On 2/25/25 at 4:30 p.m., staff did not adequately supervise Resident #2 who had severe cognitive impairment and wore a wander alert bracelet. A friend coming to visit Resident #2 found him wandering unsupervised in the parking lot and notified the facility. The facility has not determined how Resident #2 was able to leave the facility despite the wander alert bracelet.

On 3/29/25 at approximately 6:40 p.m., Resident #3, who had severe cognitive impairment and was mobile, was not adequately supervised and exited the facility without staff knowledge. A staff member leaving the facility saw the resident wandering unsupervised outside through her rearview mirror and called the nurse on duty to take the resident back inside.

The facility failure to have an effective Quality Assurance and Performance Improvement program that identify quality deficiencies and implement appropriate systemic corrective actions created a likelihood of further unsafe wandering and elopement of cognitively impaired, confused residents which could result in serious harm, serious injuries or death of the residents.

Cognitively impaired residents who exit the facility without staff knowledge and necessary supervision could cross the nearby busy four or six lane highway, get hit by a car, or sustain a fall resulting in serious injury from walking the uneven and overgrown grounds behind the facility.

This failure resulted in the determination of pattern ongoing Immediate Jeopardy.

On 4/17/25 at 9:12 a.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ).

The findings included:

Cross reference to