Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adviniacare At Naples during CMS and state inspections, most recent first.
Two residents receiving IV antibiotics through PICC lines did not receive dressing care as ordered. One resident’s PICC dressing remained dated from admission and the ordered dressing-change instructions were not entered on the MAR, while another resident’s PICC dressing was observed as an undated gauze dressing and the DON verified it had not been changed as required. Staff documentation did not match the actual care provided, and the DON confirmed the ordered PICC dressing changes were not completed.
Failure to Post Nurse Staffing Data: The facility failed to post the nurse staffing data at the beginning of each shift for 3 consecutive days. Surveyors observed the staffing sheet behind a plastic stand at the nurse's station with an outdated date, and staff interviews confirmed the night shift, Medical Records staff, and DON did not ensure it was updated and posted as required.
A resident with no natural teeth and decreased dentition did not have dental services properly coordinated. The facility lacked dental consult documentation in the chart, staff could not verify referrals or follow-up, and the resident and family reported confusion about how dentures would be paid for. The resident said he wanted dentures and payment information, while the family said they received no clear answers about coverage or responsibility.
A facility failed to use a binding arbitration agreement that clearly stated a resident or resident representative was not required to sign as a condition of admission or continued care. Three sampled residents said they could not recall being educated on arbitration or being told the agreement was optional, and the Admissions Director and DON confirmed the document did not include the required statement.
Three cognitively impaired residents with severe cognitive deficits and a history of exit-seeking behaviors were able to leave the facility unsupervised on separate occasions, despite being identified as elopement risks and equipped with wander alarm bracelets. Staff failed to monitor alarms or verify resident whereabouts, and facility doors lacked audible alarms, allowing residents to exit unnoticed. The facility's layout enabled unsupervised movement between units and to unsecured outdoor areas, with staff interviews revealing gaps in awareness and monitoring.
Three cognitively impaired residents exited the facility unsupervised on separate occasions due to staff not responding to door alarms and inadequate supervision. In each case, the residents were found outside by individuals not assigned to their care, and facility staff were unaware of their absence. Investigations revealed that alarm systems were not always audible or effective, and staff were not fully aware of the deficiencies in the door security systems.
Three cognitively impaired residents, all at risk for wandering, exited the facility unsupervised on separate occasions due to failures in supervision, monitoring, and response to door alarms. The facility did not conduct thorough investigations or implement systemic corrective actions, and the QAPI program failed to address the repeated incidents, leaving ongoing risks for further elopements.
A resident with mobility issues fell and sustained a major injury after a CNA failed to follow the care plan requiring a mechanical lift and two-person assistance for transfers. The CNA attempted to transfer the resident using a walker without verifying the care plan, resulting in the resident's fall and injury.
A resident with heart failure and a pacemaker received an incorrect dosage of Coumadin due to a nurse's failure to discontinue a previous order after receiving new instructions. This led to critically high PT/INR levels, requiring intervention. The facility did not report the incident as possible neglect to the State Survey Agency.
Failure to Maintain and Change PICC Dressings as Ordered
Penalty
Summary
The facility failed to provide appropriate care and services for 2 residents receiving IV antibiotics through PICC lines. For Resident #48, who was admitted with an infection following a procedure and had orders to continue antibiotics until 5/27/26, the record showed an order to change the IV transparent cover dressing on admission, weekly, and as needed. The MAR did not include that order, and on 5/26/26 the resident was observed with a PICC line to the left upper arm with a dressing dated 5/19/26. The resident stated the PICC dressing had not been changed since admission, and on 5/27/26 the DON verified that the dressing was still dated 5/19/26 and had not been changed since admission. The DON also verified that the physician’s orders for PICC dressing changes were not transcribed on the MAR because RN Staff A did not activate the order. For Resident #47, who was admitted with discitis and osteomyelitis of the lumbar region and had orders for IV Daptomycin and Ertapenem, the resident was observed on 5/26/26 with a PICC line to the right upper arm and an undated gauze dressing at the insertion site. The TAR showed an order to change the IV PICC transparent dressing every night shift every Friday, but on 5/22/26 RN Staff E entered “8” for the dressing change and documented in a progress note that the dressing had been changed one day ago. On 5/27/26 the DON verified that the PICC dressing had not been changed at the facility and stated that the nurse should have changed the dressing on 5/22/26. The DON also stated that when a resident is admitted with a PICC line, the nurse is supposed to change the dressing and apply a transparent dressing, then change it every 7 days.
Failure to Post Nurse Staffing Data
Penalty
Summary
The facility failed to post the nurse staffing data at the beginning of each shift for 3 consecutive days, on 5/23/26, 5/24/26, and 5/25/26. On 5/26/26 at 9:00 a.m., surveyors observed the nurse staffing data displayed behind a plastic stand at the nurse's station, and it was dated 5/22/26. Photographic evidence was obtained. During interviews on 5/28/26, an RN stated the night shift nurse should have changed the staffing data over the weekend and on Monday, and she did not notice it had not been changed on the weekend days or Monday. A Medical Records staff member stated she was responsible for posting the staffing data Monday through Friday, but she was absent on Monday and Tuesday, and the DON would have arranged for it to be posted in her absence. The DON verified that she failed to ensure the nursing data was posted on the three identified days.
Dental consults not documented or coordinated for resident needing dentures
Penalty
Summary
The facility failed to ensure dental services were appropriately coordinated for one resident who had no natural teeth and a care plan noting decreased dentition. The resident, who was admitted with diagnoses including gastro-esophageal reflux and pneumonia and had intact cognition, reported that he arrived without dentures and was seen by a dentist who took molds of his mouth. He said he told the dentist he did not know how he would pay for new dentures because his insurance did not cover them, and treatment stopped while he sought more information about payment. He stated he wanted a new set of dentures and information on how to pay for them. The resident’s daughter stated that he had been without teeth for over 2 years and that the family had ongoing difficulty getting dentures. She said the dental service provided by the facility wanted her to pay for the dentures from the responsibility she owed to the facility, which she described as a scam, and that multiple calls to the facility did not provide answers about how payment for the dentures would occur. The facility’s records initially did not contain documentation of the dental consultation, and the Social Services Director and MDS Coordinator could not find notes showing that the resident had seen a dentist or that referrals had been made. When the dental provider’s records were later obtained, they showed a dental consult in which the resident was interested in upper partial and lower dentures, the dentures were noted as approved by social work, and initial and final impressions were taken. A later dental progress note stated that the resident was scheduled for a denture consult, but the dentist office confirmed with the POA and family that the patient was not interested in moving forward with denture fabrication and no further follow-up was needed. The Administrator stated she could not explain why the July 2025 dental exam was not in the electronic medical record and did not know whether the resident or representative were aware of payment options through Medicaid.
Binding Arbitration Agreement Lacked Required Admission Language
Penalty
Summary
The facility failed to have a binding arbitration agreement that explicitly stated that neither the resident nor the resident representative was required to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility for 3 sampled residents. Review of the facility’s undated arbitration agreement showed that it did not include language stating that signing the agreement was not required for admission. The signature page stated that the undersigned had read all six pages of the agreement, waived the right to a trial before a judge or jury, and voluntarily consented to all terms of the agreement. Residents interviewed said they could not recall being educated about binding arbitration and did not know whether they had to sign it to remain in the facility. One resident said she was not aware she was in any kind of legal arbitration with the facility and that no one had told her she had to sign anything legal to reside there. Another resident said he could not remember if anyone explained what binding arbitration was or whether he had to sign it to stay. A third resident said she had no idea what binding arbitration was or whether anyone had told her she had to sign it to stay. The Admissions Director and DON both confirmed that the agreement provided to residents did not contain a statement making residents or representatives aware that they did not have to enter binding arbitration for admission or continued care.
Failure to Prevent Unsafe Wandering and Elopement of Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for cognitively impaired residents, resulting in multiple incidents of unsafe wandering and elopement. Three residents with severe cognitive impairment and a history of exit-seeking behaviors were able to leave the facility unsupervised on separate occasions. In each case, the residents were identified as being at risk for elopement, had documented exit-seeking behaviors, and were equipped with wander alarm bracelets. Despite these precautions, staff did not consistently monitor alarms or verify the whereabouts of residents when alarms were triggered. One resident with dementia and a history of attempted elopement exited the facility through the front door, setting off the alarm. Staff turned off the alarm without checking on residents with wander alert bracelets, and the resident was later found unsupervised in the parking lot by a staff member on break. Another resident with severe cognitive impairment and a wander alarm bracelet was found wandering in the parking lot by a visitor, with no staff aware of the resident's absence. A third resident with a traumatic brain injury and severe cognitive impairment was found outside the facility by a staff member leaving work, after having exited without staff knowledge. Observations revealed that the facility's entrance doors did not have audible alarms, and staff were not consistently present to monitor exits. The physical layout allowed residents to move freely between the skilled nursing facility and an adjoining assisted living facility, with unsecured hallways and proximity to busy roads. Staff interviews confirmed a lack of awareness regarding the functionality of alarm systems and the risks posed by unsecured exits. The facility had not conducted elopement drills or reassessed all residents for elopement risk following these incidents.
Failure to Prevent Elopement of Cognitively Impaired Residents Due to Ineffective Supervision and Alarm Systems
Penalty
Summary
The facility administration failed to utilize its resources effectively to ensure the safety of three cognitively impaired residents, resulting in multiple incidents of unsafe wandering and elopement. One resident with severe cognitive impairment and a wander alarm bracelet exited the facility without appropriate staff response to the door alarm and was found unsupervised in the parking lot by a staff member on break. Another resident, also with severe cognitive impairment and a wander alarm bracelet, exited the facility without staff knowledge and was found wandering in the parking lot by a visitor, who then notified the DON. A third resident, who was mobile and had severe cognitive impairment but was not initially identified as an elopement risk, exited the facility unsupervised and was found outside by a staff member leaving work. The facility's investigations revealed that staff did not respond appropriately to door alarms, and in some cases, were unaware that residents had exited the building. The facility's elopement prevention policy required functional alarm systems and staff education, but observations showed that alarms were not always audible at the nurse's station and that staff did not consistently respond to them. Additionally, the front entrance door locked when a wander alert bracelet was detected but did not have an audible alarm, and staff were not aware of this deficiency. The Maintenance Director confirmed that issues with the doors had been ongoing and that elopements typically occurred through the front door, which lacked an effective alert system. Interviews with the Administrator and DON indicated a lack of awareness regarding the functionality of the entry doors and the potential for residents to exit undetected, especially by following others through already opened doors. The Administrator, new to the facility, acknowledged that she was still learning about the systems in place and had not made significant changes to door security beyond discussing possible upgrades. The facility's failure to ensure effective supervision and functional alarm systems for residents at risk of elopement led to the determination of Immediate Jeopardy.
Failure to Investigate and Prevent Multiple Resident Elopements
Penalty
Summary
The facility failed to thoroughly investigate multiple elopement incidents involving three cognitively impaired residents who were at risk for wandering. Each of these residents either wore a wander alert bracelet or was known to be mobile and confused, yet managed to exit the facility unsupervised. In one instance, a resident with severe cognitive impairment and a wander alert bracelet exited the building, setting off the door alarm, but staff did not respond appropriately. The resident was found wandering in the parking lot by a staff member who was outside on break. In another case, a resident with similar cognitive impairment and a wander alert bracelet was found unsupervised in the parking lot by a visitor, with the facility unable to determine how the resident left despite the bracelet. A third resident, also severely cognitively impaired and mobile, exited the facility without staff knowledge and was only noticed by a staff member leaving the premises. The facility's Quality Assurance and Performance Improvement (QAPI) program did not identify or address the systemic issues that allowed these elopements to occur. The investigations into the incidents did not uncover critical failures, such as the lack of an audible alarm on exit doors or the absence of monitoring to prevent residents from following visitors out. The QAPI committee did not develop or implement a Performance Improvement Plan (PIP) to address the repeated incidents, and there was a lack of comprehensive root cause analysis. The Administrator and DON acknowledged that elopement drills were not conducted after the incidents and that only one QAPI meeting had been held since the Administrator's employment began. The facility's response to the incidents was limited to updating care plans and providing some staff education, without systemic corrective actions. Interviews with facility leadership and staff revealed gaps in supervision, monitoring, and understanding of elopement risks. The Administrator was unaware of certain vulnerabilities, such as residents being able to exit with visitors or the nurse's station being frequently unattended. The DON and other staff confirmed that not all residents at risk had appropriate interventions in place, and that the facility's investigations did not fully address the underlying causes of the elopements. The lack of effective QAPI oversight and failure to implement systemic changes created an ongoing risk for further unsafe wandering and elopement among cognitively impaired residents.
Removal Plan
- Educated staff on residents at risk for elopement and elopement interventions.
- Staff educated on new process for doors to be locked and someone will have to allow entrance and exit of residents, families and guests.
- 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.
- Elopement drills will be done on all shifts.
- Elopement drills were conducted.
Failure to Follow Transfer Plan Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the established plan of care for a resident, resulting in an avoidable fall and major injury. The resident, who was admitted with diagnoses including morbid obesity and a left artificial knee joint, was assessed to be dependent on assistance for toilet transfers. The care plan specified the use of a full body mechanical lift with the assistance of two staff members for transfers. However, on the day of the incident, a CNA did not follow this plan. Instead, the CNA attempted to transfer the resident using a walker and without the required assistance, leading to the resident falling and sustaining a displaced comminuted fracture of the right tibia. The incident occurred after the resident, who had intact cognition, informed the CNA that she no longer needed the mechanical lift or additional staff for assistance. The CNA did not verify this information with the care plan or nursing staff. The resident's fall was attributed to the CNA's failure to check the Individual Service Plan for proper transfer instructions. Interviews revealed that the CNA did not receive adequate training on accessing care plans or using mechanical lifts, and the Director of Nursing confirmed that not all staff had been trained in these areas.
Failure to Report Medication Error as Possible Neglect
Penalty
Summary
The facility failed to report an incident of possible neglect to the State Survey Agency concerning a medication error involving a critical medication for a resident. The resident, who had a history of heart failure and a cardiac pacemaker, was prescribed Coumadin, a blood thinner, with specific dosage instructions. The facility's policy required nurses to review medication orders and update them based on laboratory results. However, after receiving abnormal PT/INR results, a registered nurse notified the physician and received new dosage instructions but failed to discontinue the previous order. This oversight led to the resident receiving an incorrect dosage of Coumadin for three consecutive days. As a result of the medication error, the resident's PT and INR levels became critically high, prompting the physician to discontinue Coumadin and administer Vitamin K to lower the INR value. Despite the severity of the incident, the Executive Director did not consider it as possible neglect and failed to submit a Federal Report to the State Survey Agency. This omission highlights a significant deficiency in the facility's reporting procedures for incidents of potential neglect.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Naples
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Senior Living North Naples | 2.2 mi | ★★★★★ | 0 | 0 |
| Chateau At Moorings Park, The | 2.9 mi | ★★★★★ | 1 | 0 |
| Premier Place At The Glenview | 3 mi | ★★★★★ | 3 | 0 |
| Solaris Healthcare Imperial | 4 mi | ★★★★★ | 0 | 0 |
| Naples Health And Rehabilitation Center | 4.4 mi | ★★★★★ | 14 | 3 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.