Manorcare Nursing And Rehabilitation Center

F-F689.

Review of the Administrator's job description revealed, The Administrator administers, directs, and coordinated all functions of the facility to assure that the highest degree of quality of care is consistently provided to the patients . Responsibilities: . Understand the facility's care regulations and support the patient care program by regularly meeting with the Patient Services Director to discuss and address concerns of the department . Ensure adherence to the Patient's [NAME] of Rights . Operate the facility in accordance with (name) Care Center policies and federal, state and local regulations . Assist in the Quality Assurance and Performance Improvement (QAPI) process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 The form noted, Employee signature below constitutes employees understanding of the requirements, essential functions and duties of the position. Level of Harm - Immediate jeopardy to resident health or The Administrator signed the job description on 12/9/24. safety

Review of the Director of Nursing job description revealed, Overview: Executes the goals and objectives of Residents Affected - Few the nursing department in regard to patient/resident rights, patient/resident care and reflects the mission statement of the facility . Provides leadership and direction for the nursing staff while being responsible for

the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. Responsibilities: . Ensure compliance with government and accrediting agency standards and regulations pertaining to Nursing. Directs systems and programs within the department designed to meet regulatory standards. Assess, coordinate, plan and implement the systems required to deliver a high standard of care to patients/residents . Participate in QA/PI Programs by providing for the collection and analysis of data for the continuous quality improvement program . Ensure residents' safety in accordance with resident safety program .

The form noted, Employee signature below constitutes employees understanding of the requirements, essential functions and duties of the position.

The interim DON signed the form on 5/5/25.

Review of the clinical record revealed Resident #53 was admitted to the facility from an acute care hospital

on 4/26/25.

Review of the hospital physician discharge summary dated 4/26/25 revealed Resident #53's main problem

during the hospital admission had been delirium [serious changes in mental abilities resulting in confused thinking and lack of awareness of surroundings], active delirium and agitation. The practitioner documented,

We do suspect this patient has Alzheimer [sic] dementia. She was treated with Seroquel [antipsychotic] while here . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on .

On 5/1/25 the attending physician signed a statement noting in his opinion Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient explanation without coercion or undue influence.

On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors including not staying in one spot. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. LPN Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A 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 clinical record lacked documentation of Resident #53's wandering behavior and the elopement incident. LPN Staff A said, It was all just verbal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 when Resident #53 exited the facility. She said earlier that day, before they knew Resident #53 was gone, she heard the door Level of Harm - Immediate alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired jeopardy to resident health or residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS (Emergency Medical safety Services) showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. A little bit after that LPN Staff A was going down the hall looking for Resident #53 but could Residents Affected - Few not locate her. The Administrator and Director of Nursing (DON) were notified and came to the facility. Staff B and Staff A went to the gas station recognized Resident #53 and brought her back to the facility.

On 5/12/25 at 12:32 p.m., in an interview, the interim DON verified on 5/2/25 Resident #53 exited the facility through the back door and was found at the gas station across the street. She said upon the resident's return, she evaluated the resident's cognition. Resident #53 was alert and oriented and scored 13 on the Brief Interview for Mental Status, indicative of intact cognition. The DON said they conducted a soft investigation. They did not consider the incident an elopement but a near miss. The interim DON said 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 soft investigation determined the incident did not meet criteria for elopement as the resident was able to demonstrate how she left the facility and was taught as a child to look both ways to cross the street. The DON said as part of elopement prevention, the facility's front door, the 200 hall door and the 400 hall exit door are equipped with a wander alarm system. The wander alert bracelets would set off the alarm if

a resident attempted to go through the doors. She said the other doors have an egress bar that alarms if opened and can only be shut off with a key.

On 5/12/25 at 3:10 p.m., in an interview, the Administrator verified on 5/2/25 the staff called him, said they could not find Resident #53 and had called a code orange. They did a root cause analysis of the incident and determined it was not an elopement. The Administrator said it was a near miss since the resident was cognitively intact, knew where she was going, and had not been incapacitated. The near miss incident was discussed in the Quality Assurance and Performance Improvement meeting on 5/9/25 but no performance improvement plan was put in place since they did not consider the incident an elopement. The Administrator 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.

When asked about the incapacity statement signed by the attending physician on 5/1/25, the Administrator said, Had I known Resident #53 was incapacitated, I would have considered the incident an elopement without a doubt.

The Administrator said they conducted elopement drills the next day and retrained staff on the elopement policy. He said at least 75% of the staff were reeducated on the elopement policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 facility's Standards and Guidelines: Elopement and Wandering revised on 1/1/24 provided by

the DON on 5/12/25 revealed, The facility will identify residents who are at risk of unsafe wandering and Level of Harm - Immediate strive to prevent harm while maintaining the least restrictive environment for incapacitated residents . jeopardy to resident health or Definition: A situation in which an incapacitated resident leaves the facility grounds or a safe area without the safety facility's knowledge and supervision, if necessary, would be considered an elopement . Each incapacitated resident will be assessed for wandering upon admission, readmission, and whenever an elopement attempt Residents Affected - Few or new wandering behavior is observed or identified. If an incapacitated resident is missing who is considered at risk, initiate the elopement/missing resident emergency procedure . Announce Code Orange [facility's code to alert staff of a missing resident]. Note the time that the resident was discovered missing, or

the door alarmed.

On 5/12/25 at 3:32 p.m., in an interview, the interim DON said she did not know on 5/1/25 the attending physician had signed an incapacity statement for Resident #53. She said definitely the incident would have been considered an elopement and would have been reported for sure.

On 5/13/25 at 1:42 p.m., in an interview, the interim DON reviewed part of the soft file investigation. It included a near miss/missing resident checklist, elopement drills, elopement in-services, and door alarm testing.

On 5/14/25 at 10:40 a.m., the DON provided a Standards and Guidelines: Elopement and Wandering policy revised 1/1/2025. She said she did not realize the policy had been updated. The policy read, A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement and the situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle.

The procedure only considered incapacitated residents and read in part, If identified at risk for wandering, elopement, or other safety issues, the incapacitated resident's care plan will include strategies and interventions to maintain the incapacitated resident's safety.

Each incapacitated resident will be assessed for wandering and elopement upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified.

On 5/15/25 at 10:14 a.m., in an interview, the interim DON said if staff hear an alarm go off, they are supposed to go to the door, check the surrounding area outside to see if a resident exited, do a head count and call a code orange. The DON said the function of the wander alert bracelets is checked daily.

On 5/16/25 at 12:22 p.m., during a review of the facility's Quality Assurance and Performance Improvement program, the Administrator reviewed the facility's Performance Improvement Plans (PIPs). He verified there was no current PIP related to elopement prevention.

Review of the facility's neglect investigation initiated on 5/12/25 related to Resident #53's elopement revealed Resident #53's incapacity statement completed and signed by the attending physician on 5/1/25 was not uploaded to the resident's chart until 5/8/25 after the resident's discharge. The investigation also noted all the exit doors were checked for proper functioning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 5/16/25 at 2:20 p.m., the DON demonstrated the function of the wander alert bracelets for the six current residents identified at risk of elopement. Level of Harm - Immediate jeopardy to resident health or Resident #24 was identified at risk for elopement and wore a wander alert bracelet. When checked, the light safety 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. Residents Affected - Few The DON verified the wander alert bracelet was not functioning and said she would place the resident on 1 to 1 supervision until the wander alert bracelet could be replaced.

Resident #59 was identified at risk for elopement and wore a wander alert bracelet. When the DON checked

the resident's wander alert bracelet, a red light came on. The DON said the red light meant the wander alert battery was low. She said she would have it replaced immediately.

On 5/16/25 at 2:45 p.m., a tour of the facility was completed with the Maintenance Director and the Maintenance Assistant to check the alarm system and function of the egress doors.

The Maintenance Director explained when an egress door is pushed open, a very loud alarm will sound.

The Maintenance Director pressed on the Heritage Hall East egress door bar. The door made a beeping sound. The Maintenance Director opened the door fully. The door alarm did not come on.

The Maintenance Director then checked the Heritage Hall [NAME] egress door. The door made a beeping sound when pressed. The Maintenance Director pushed the door open. The alarm did not come on.

On 5/16/2025 at 2:55 p.m., the Maintenance Director said the two egress doors should have sounded loudly when opened. He instructed the Maintenance Assistant to fix both doors.

On 5/16/25 at 3:00 p.m., observation of the dining room with the Maintenance Director revealed an exit door that led to a screened porch. The Maintenance Director said the door was a mag locked door and could not be pushed open. The Maintenance Director demonstrated by pushing the door. The door easily opened and did not alarm. The Maintenance Director said, The door should not be able to be opened. My guy was out here power washing earlier.

As of the exit date of 5/16/25 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 to prevent unsafe wandering and elopement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 105421

F-F835.

Review of the clinical record revealed Resident #53 was admitted to the facility from an acute care hospital

on 4/26/25.

Review of the hospital physician discharge summary dated 4/26/25 revealed Resident #53's main problem

during the hospital admission has been delirium (serious changes in mental abilities resulting in confused thinking and lack of awareness of surroundings), active delirium and agitation. The practitioner documented,

We do suspect this patient has Alzheimer [sic] dementia. She was treated with Seroquel (antipsychotic) while here . I do not think this patient can go back to her independent living facility. She will need constant supervision from now on .

The patient transfer form (Agency for Health Care Administration Form 3008) dated 4/26/25 noted Resident #53 was alert, disoriented but could follow simple instructions. Resident #53 ambulated with assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 0689 The Admission Nursing Evaluation note dated 4/26/25 at 9:35 p.m., noted Resident #53 has no weight bearing restrictions. The resident utilizes the following mobility devices: Walker, Wheelchair. Level of Harm - Immediate jeopardy to resident health or Review of the elopement risk evaluation dated 4/26/25 at 9:35 p.m. revealed the nurse completing the form safety entered No for the following questions:

Residents Affected - Few Resident has cognitive status impairment (i.e. short-term memory loss, BIMS (Brief Interview for Mental Status) score, diagnosis, etc.),

Does the resident have the ability to ambulate independently (with or without use of assistive device/wheelchair)?,

Does the resident exhibit exit-seeking behavior (e.g. walk towards exits, manipulate doors, handles etc.).

The facility determined Resident #53 was not an elopement risk but checked Increased staff observation in

the Interventions/Approaches section of the elopement evaluation.

Review of the behavior monitoring on the Medication Administration Record (MAR) for April 2025 revealed Resident #53's documented behaviors did not include wandering.

Review of the progress notes revealed on 4/27/25 at 6:37 a.m., Resident #53 was sitting on the floor next to her bed. Her oxygen was off. Resident #53 was yelling at the nurse, You're trying to murder me, you're in love with my husband, you're having an affair with him. The nurse documented the resident was very confused and became more lucid with the oxygen on at 3 liters.

On 4/29/25 at 1:27 a.m., a nursing progress note documented Resident #53 was standing naked in the hallway yelling, calling this nurse a witch and refusing to put O2 (oxygen) on.

On 4/29/25 at 2:30 a.m., a nursing progress note documented the resident continued to yell at staff; sat on

the floor from the wheelchair trying to hit and kick staff. The resident kicked and scratched the nurse. When

the oxygen was put on, the resident became calmer.

On 4/30/25 at 6:22 a.m., a Social Service progress note documented speaking to the resident's son. The son said he did not feel his mother could return to independent living and was looking into memory care facilities.

The son shared that Resident #53 has had paranoid behaviors for some time now. She would call the police and say her son was beating her and taking her money.

On 5/1/25, an initial psychiatric evaluation progress note documented Resident #53 had a psychiatric history of dementia with other behavioral disturbances, delirium and insomnia. Resident #53 was observed sitting in her wheelchair. She was alert with severe cognitive impairment. Resident #53 scored a 5 on the BIMS which indicated severely impaired cognition. The resident was difficult to redirect. The practitioner documented Resident #53 was unstable. The symptoms were occurring daily and causing severe distress. The practitioner discontinued the Seroquel and ordered Depakote sprinkles 250 mg three times daily (Used to manage irritable mood and impulsivity).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 0689 On 5/1/25, the attending physician signed a statement noting in his opinion Resident #53 no longer had the capacity to make knowing health care decisions for herself or provide informed consent after a sufficient Level of Harm - Immediate explanation without coercion or undue influence. jeopardy to resident health or safety On 5/12/25 at 12:08 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said on 5/2/25 she was assigned to Resident #53. She said historically Resident #53 was confused and often had extreme behaviors Residents Affected - Few including not staying in one spot. LPN Staff A said she usually kept a close eye on Resident #53, as she liked to wander. LPN Staff A said on 5/2/25 she had been with a different resident when she noticed Resident #53 was gone. Staff A 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. She said Resident #53 explained how she went out the back door and pushed the egress bar for 15 seconds to be let out. LPN Staff A said the door alarm did go off. She notified the Director of Nursing (DON), the Administrator, and called the family. LPN Staff A verified Resident #53's wandering behavior and not staying in one spot were not documented in the clinical record. She verified the lack of documented individualized interventions, including necessary and adequate supervision to ensure Resident #53's safety and prevent elopement. LPN Staff A said she had no explanation for the lack of documentation. She said, It was all just verbal.

On 5/12/25 at 12:40 p.m., in an interview, LPN Staff B said she was on duty on 5/2/25 but was not directly working with Resident #53 when she left the building. LPN Staff B said EMS (Emergency Medical Services) came to the facility and said they had found someone at the gas station and were trying to find out where that person belonged. They did not recognize the name provided by EMS. LPN Staff A searched in the computer and could not locate any resident with the last name EMS provided. LPN Staff B said a little bit

after that LPN Staff A was going down the hall looking for Resident #53 but could not locate her. LPN Staff B said earlier that day, before they knew Resident #53 was gone, she had heard the door alarm by room [ROOM NUMBER] and 332 go off. LPN Staff A said it was one of her visually impaired residents who had pushed on the door causing it to alarm. She shut the alarm off. EMS showed up at the facility 20 to 30 minutes after she heard the door alarm to see if they had a missing resident. The Administrator and Director of Nursing (DON) were notified and came to the facility. Staff B and Staff A went to the gas station recognized Resident #53 and brought her back to the facility.

On 5/12/25 at 12:32 p.m., in an interview, the interim DON verified on 5/2/25 Resident #53 exited the facility through the back door and was found at the gas station across the street. She said upon the resident's return, she evaluated the resident's cognition. Resident #53 was alert and oriented and scored 13 on the Brief Interview for Mental Status which indicated intact cognition. She said she was not aware on 5/1/25 the psychiatrist noted Resident #53's cognition was severely impaired and scored a 5 on the BIMS. The DON said they conducted a soft investigation. They did not consider the incident an elopement but a near miss.

The DON said Resident #53 knew what she was doing and was able to describe it that Friday and again the next day on Saturday.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 0689 On 5/12/25 at 3:10 p.m., in an interview, the Administrator verified on 5/2/25 the staff called him, said they could not find Resident #53 and had called a code orange (Code used by the facility to alert staff of a missing Level of Harm - Immediate resident). The Administrator said they did a reenactment with Resident #53. She took him to the exit door jeopardy to resident health or and was able to demonstrate how she opened the door. She was able to do it again the next day. The safety Administrator said they did not consider it an elopement. The Administrator said they did elopement drills the next day and retrained staff on elopement. They did a root cause analysis of the incident and determined it Residents Affected - Few was not an elopement. The Administrator said the incident was discussed in the Quality Assurance and Performance Improvement meeting on 5/9/25 but no performance improvement plan was put in place since

they did not consider it an elopement.

On 5/13/25 at 1:02 p.m., the hospital discharge summary noting Resident #53 required constant supervision and a potential diagnosis of Alzheimer's disease was reviewed with the DON. She said constant supervision did not mean the resident was exit seeking. It meant she needed to be in a skilled nursing facility.

On 5/15/25 at 10:14 a.m., in an interview, the Interim DON said if staff hear an alarm go off, they are supposed to go to the door, check the surrounding area outside to see if a resident exited, do a head count and call a code orange.

On 5/16/25 at 3:34 p.m., in a telephone interview, Resident #53's son said the facility notified him of the elopement. He said it should never have happened, absolutely not. He said the facility called and told him

they no longer could provide services for her. It's been an ongoing battle for two to three years. She did not have a place to go due to her behaviors. The son said his mother has always had wandering behaviors. She had the behavior when she was living with him.

Review of the facility's Standards and Guidelines: Elopement and Wandering revised on 1/1/24 provided by

the DON revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for incapacitated residents . Definition: 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 . Each incapacitated resident will be assessed for wandering upon admission, readmission, and whenever an elopement attempt or new wandering behavior is observed or identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 105421 Department of Health & Human Services Printed: 08/27/2025 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 105421 B. Wing 05/16/2025

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

Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112

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 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37256 jeopardy to resident health or safety Based on observation, record review and staff interviews, the facility administration failed to utilize its resources effectively to ensure processes were in place and implemented to prevent neglect and maintain Residents Affected - Few the safety of cognitively impaired and confused residents to prevent unsafe wandering and elopement.

Resident #53 was a vulnerable adult with severe cognitive impairment, confusion and multiple behaviors such as yelling out, disrobing in the hallway and constant wandering.

On 5/2/25 at an unknown time after 6:00 p.m., staff failed to adequately supervise Resident #53. Resident #53 exited the facility without staff knowledge and necessary supervision.

Staff were not aware of the resident's exit until 5/2/25 at approximately 7:00 p.m.

On 5/2/25 at an unknown time after 7:00 p.m., Resident #53 was found at a gas station located approximately 0.1 mile from the facility. Resident #53 crossed a busy four lane road to get to the gas station located on a busy eight lane highway.

The facility administration failed to recognize the neglect of Resident #53 and called the resident's elopement

a near miss. The facility administration failed to complete a thorough investigation and failed to implement immediate and appropriate action to prevent the neglect of other cognitively impaired, confused and mobile residents to prevent further incidents of unsafe wandering and elopement.

The facility administration failure to use its resources effectively to maintain residents' safety created a likelihood of serious harm, serious injury or death of Resident #53 and other cognitively impaired residents who exit the facility without staff knowledge. The residents 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.

This failure resulted in the determination of Immediate Jeopardy.

The findings included:

Cross reference