Woodside Health And Rehabilitation Center

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

They just come in turn the light off and don't say anything. Yesterday was terrible, it was pretty bad. I had to go so badly to have a bowel movement and I went in my pants because no one came. They did not come for about an hour. The service here is terrible and it is worse on the night shift. I always wait over an hour. It makes me feel sad. I don't like to be like that, like I was yesterday, with stool on me.Review of the clinical

record revealed Resident #799 was an [AGE] year-old male admitted on [DATE REDACTED] with diagnoses including chronic kidney disease stage 3, type 2 diabetes mellitus, and hypertensive heart disease.Review of the admission MDS dated [DATE REDACTED], documented that the resident was frequently incontinent of bowel and bladder and was not on a training program. The MDS specified the resident required substantial to maximum assistance with transfers to the toilet. The MDS documented a BIMS score of 08 indicating the resident's cognition was moderately impaired.The care plan initiated 10/23/25 identified Resident #799 had

an activities of daily living (ADL) selfcare deficit related to fatigue, and chronic medical conditions.The goal for the resident specified he would not have a decline in ADL functioning through next review date.The interventions instructed staff to encourage and educate resident with increased independence as tolerated and assist with all ADL tasks as indicated, including transfers, toileting tasks, and personal/oral hygiene.

Toileting: the resident will need extensive help of one or two staff. The resident will probably need you to wipe, redress, and wash their hands. Be prepared with 2 people to assist for resident safety during the transfer.On 11/13/25 at 8:30 a.m., in an interview RN Staff C said the call lights are to be answered as soon as you realize it is on. As soon as possible, take care of the resident.On 11/13/25 at 8:50 a.m., in an

interview the Administrator said the call light response is a no pass zone, meaning everyone was to answer

the call lights and not walk past them. He said, We have provided education, and the Leadership Staff are to be out on the floor making sure call lights are answered. It continues to be a problem, and we are working on it.A review of the training provided by the facility on 11/3/25 on call lights and customer service, documented it was very important that you must answer all call lights in a timely manner. Please knock on

the door and wait for answer, enter room with a smile, a smile goes a long way, even if it's not your section,

they are all our residents.A total of 23 employees received the training.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

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 0565

Honor the resident's right to organize and participate in resident/family groups in the facility.

Level of Harm - Minimal harm or potential for actual harm

Based on review of the Resident Council Meeting Minutes and resident and staff interviews, the facility failed to act promptly upon the grievances expressed by the residents and the Resident Council group.The findings included:A review of the Resident Council meeting minutes for August 2025 through November 2025 revealed ongoing concerns related to call light response time.On 8/19/25 the Resident Council New Business documented Staff need to make sure call lights are always in reach. CNA's (Certified Nursing Assistants) need education on call light answering. Residents would like quicker call light response on weekends.There was no documentation to address the concerns with the call light response time.On 9/16/25 the Council meeting minutes documented expressed under new business Regarding weekend CNA's some residents cannot get as quick of a response to call lights; more mobile residents will help locate them. Is this appropriate?There was no documented response from the facility to address the concerns.On 10/7/25 the Resident Council meeting minutes documented under New Business, CNA's are turning off call lights and not coming back or following through with what they said they would do. Wait times for CNA's are up to 30 to 45 minutes, especially if they are doing showers. Weekends are worse.There was no documented response from the facility to address the concerns.On 10/21/25 the Resident Council minutes documented Review of previous meeting, outstanding issues. Nursing still needs to answer, waiting for responses.There was no documented response from the facility to address the concerns.On 11/4/25 the Resident Council meeting minutes documented under New Business, Education for all staff on reminding them to make sure call light is within reach. Some residents complained that the customer service overnight is not what they would like, and call lights are not answered promptly.There was no documented response from the facility to address the concerns.On 11/12/25 at 8:50 a.m., in an interview Resident #850 (Resident Council President) said the staff do not even come in the room to answer the call light. They just reach their hand in the door and turn it off. The Resident demonstrated how the call system light was located inside of

the door on the left side of the wall. She said, They just reach in and shut it off. If I really need something, I just go to the nurse's station and look for help because I can walk.On 11/13/25 at 11:00 a.m., in an interview, the Social Service Director said she knew call lights were a concern and they were working on it.

The Social Service Director did not have documentation of how the facility addressed the repeated concerns related to call light response voiced by the Resident Council from August through November

1. 2025. She said, If I hear of a concern from the Council, then I write a grievance for it and deliver it to the

appropriate person to resolve it.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Based on review of the facility nursing assignments and staff interviews, the facility failed to have a designated Licensed Nurse to serve as a charge nurse on the 11:00 p.m., to 7:00 a.m. shift as required.The findings included:On 11/12/25 at 5:35 a.m., Licensed Practical (LPN) Nurse Staff A answered the door upon arrival to the facility. A request was made to speak with the designated charge nurse. In an interview, LPN Staff A said there was no charge nurse assigned to the 11:00 p.m., to 7:00 a.m., shift. LPN Staff A said there has never been an assigned charge nurse on the night shift. She said if an emergency occurred

the staff were to contact the Director of Nursing (DON).On 11/12/25 at 5:50 a.m., in an interview LPN Staff B confirmed there was no designated charge nurse on duty for the shift. She said there never is a designated licensed nurse to serve as a charge nurse for the night shift. Staff B said, If we have a problem

we call the DON.On 11/12/25 at 6:45 a.m., in an interview LPN Staff E said there was no charge nurse assigned on the night shift. She said they call the DON for emergencies. Review of the 11-7 shift nurse assignments from 11/5/25 through 11/12/25 revealed there was no designated charge nurse assigned for

the night shift.On 11/13/25 at 1:23 p.m., in an interview the DON said the facility did not have an assigned charge nurse as required on the 11:00 p.m. - 7 a.m., shift, the staff just call the DON.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

not come in from Pharmacy and then my cycle has to start over. I don't know why they don't order it a day in advance because they know I get it every other day, but they don't have it here.

Review of the physician orders documented an order dated 10/18/25 for Cubicin Solution (an antibiotic) Reconstituted 500 milligrams (mg). Use 500 mg intravenously every 48 hours for osteomyelitis until 11/11/2025.

A review of the medication administration record (MAR) for October 2025 revealed on 10/19/25 the documentation indicated the medication was not administered and was reordered on 10/24/25.

Further review of the MAR revealed the Cubicin Solution was not administered on 10/26/25, 10/28/25 and 10/30/25.

Review of the nursing progress note dated 10/26/25 documented the Cubicin was not administered, awaiting pharmacy delivery.

There was no documentation the physician was notified of the missed dose.

The nursing progress note dated 10/28/25 documented patient refused, stated that the last dose was administered yesterday at 6 a.m. Nurse Practitioner notified and okay to reschedule start on 10/29/25 at 6:00 a.m. Resident aware and agreed with the changes.

The nursing progress note dated 10/30/25 documented Cuibcin Solution Reconstituted 500 mg was not administer as the medication was completed on 10/29/25.

A review of the November MAR documented a start dated of 10/31/25 for Cuibcin Solution Reconstituted 500 mg IV every 48 hours with a discontinue date of 11/3/25. On 11/2/25 the MAR indicated the medication was not administered.

A review of the nursing progress note dated 11/2/25 documented the medication was not administered, awaiting Cubicin from pharmacy.

The medication was reordered on 11/5/25 to continue until 11/11/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, review of facility policy and procedure and staff interviews, the facility failed to ensure medications were stored in locked compartments when not in use in 1 ([NAME] Hallway) of 3 hallways observed to prevent unauthorized access to medications.The findings included:Review of the facility policy and procedure titled, Medication Storage and Labeling revised 1/2024 revealed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Procedure: Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications.On 11/12/25 at 5:40 a.m., during the initial tour of the facility, observation of

the [NAME] Unit Hallway revealed two medication carts:The first cart had two prefilled syringes of Normal Saline Solution 0.9%, a bottle of powdered Cefazolin (antibiotic) 2 grams for Resident #700, and an intravenous bag of 50 milliliters normal saline that were unlocked and unattended on top of the medication cart. Photographic evidence obtained.On 11/12/25 at 5:44 a.m., Licensed Practical Nurse (LPN) Staff A was observed coming out of a resident's room. In an interview LPN Staff A verified the 2 prefilled syringes of Normal Saline Solution 0.9%, the bottle of powdered Cefazolin 2 grams and the 50 milliliters bag of normal saline were left unattended and unlocked on top of the medication cart. She said she should have locked them in the medication cart.A second medication cart located approximately 10 feet from the first cart was observed unlocked and unattended. Photographic evidence obtained.On 11/12/25 at 5:45 a.m.,

observation of the medication cart with LPN Staff A revealed the cart contained residents' medications. In

an interview, LPN Staff A verified the medication cart was unlocked and unattended and said, Other nurses use the cart too. LPN Staff A walked away, left the cart unlocked and unattended. On 11/13/25 at 5:50 a.m., LPN Staff B verified the medication cart remained unlocked and unattended. In an interview, LPN Staff B said the medication cart should always be locked when not in use.On 11/12/25 at 1:57 p.m., during an interview, the Assistant Director of Nursing and the Administrator were informed of the observation of the medications left unsecured and unattended on the [NAME] Unit Hallway. The ADON and Administrator did not provide additional information or explanation related to the unsecured medications observed on the [NAME] Hall Unit.

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