Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Naples Health And Rehabilitation Center during CMS and state inspections, most recent first.
Delay in Starting Antibiotics for Positive Wound Culture: A resident with an abdominal wound, ileostomy, and recent surgical aftercare had a wound culture that grew E. coli, but the positive result was not communicated promptly and antibiotics were not started until several days later. The wound nurse, LPN, DON, ADON, administrator, and NP all confirmed the delay, and the resident reported she believed she was already supposed to be receiving antibiotics.
A resident with an abdominal wound, ileostomy, and history of sepsis had a wound culture that grew E. coli, but the result was not promptly reported to the ordering practitioner. Staff documented the culture result, discussed the resident’s pain and redness, and noted the resident asked about antibiotics, yet the NP was not notified until several days after the lab finalized. Interviews with the wound care nurse, LPN, NP, DON, ADON, and Administrator confirmed the delay in communication and treatment.
Unsecured lighters were found in the rooms or clothing of four residents who smoked, despite facility policy stating smoking materials and lighters were not to be kept in residents’ possession. Surveyors observed one resident flick a lighter to produce a flame, another keep a lighter in his pocket and cigarettes on a bedside table, a third leave a lighter unattended on a bedside table until the DON removed it, and a fourth keep cigarettes and a lighter in his shirt pocket. Records showed cognitive impairment, confusion, and multiple medical and behavioral conditions among the residents involved, and the DON and Administrator acknowledged residents were keeping smoking items themselves.
Unsafe resident smoking practices and unsecured ignition devices were found for four residents. Residents with diagnoses including MS, mental health disorders, substance use disorders, COPD, and repeated falls were observed or reported keeping cigarettes and lighters in rooms or on their person, including one resident who produced a visible flame with a lighter. The DON said residents had been educated and the Administrator said the smoking concerns had not been identified until the survey.
The facility failed to enforce its smoking policy for four residents who smoked. Staff observed residents keeping cigarettes and lighters in rooms or on their person, including one resident with a lighter producing a visible flame and another with an unsecured lighter on a bedside table. Records showed inconsistent smoking evaluations, care plans that did not fully address monitoring or supervision, and one resident without a signed smoking contract. The DON and MDS nurse acknowledged gaps between the smoking policy and resident practice.
A facility failed to provide enough nursing staff to meet resident needs and respond promptly to call lights. Residents reported waiting 30 minutes to 2 hours, and one resident said she waited 6 hours in urine. A resident with dementia and a prior femur fracture was observed trying to get to the bathroom while a CNA turned off her call bell and left without helping. Multiple residents and CNAs described short staffing, especially on nights, with heavy assignments and delays in toileting, colostomy care, pain meds, and other assistance.
Medications were left unsecured at the bedside for four residents, including a tablet, an inhaler, and medication cups with tablets inside. Residents stated staff left the medications for later use or that they sometimes did not take them. The DON said no resident should have medications at the bedside and no residents were care planned for self-administration, while an LPN said she left one resident's TUMS for later when the resident was ready.
Failure to Respond to Resident Council Grievances: Residents reported long waits for care, staffing shortages, slow call light response, delayed pain meds, and delayed showers. Resident Council minutes showed the same call light concern remained not resolved across multiple meetings, and the Social Services Director confirmed there was no documentation that the concern was resolved.
Failure to promptly resolve and follow up on grievances: multiple cognitively intact residents reported slow call light response times, long waits for assistance, and no meaningful follow-up after filing grievances. Although the grievance log marked some concerns as resolved, residents said the issue continued, and the Social Services Director confirmed there was no documentation that the call light concerns were resolved.
PASRR assessments were not completed accurately for two residents, and Level II screenings were not completed when required. One resident had major depressive disorder and severe cognitive impairment, and another had bipolar disorder and was cognitively intact, but their Level I PASRRs did not document the diagnoses correctly. The DON, Director of Admissions, Unit Manager, and Director of Social Services all identified that the PASRRs were incorrect and that Level II PASRRs should have been completed.
Failure to Maintain Resident Grooming and Nail Hygiene: A cognitively intact resident who needed ADL assistance was observed with fingernails that were uneven, about 3/4 inch long, and dirty under the nails, along with uncombed hair and a long beard. The resident said he had asked staff multiple times over several months to trim his nails, while the ADL record did not document refusals or routine encouragement. The RN UM and DON confirmed staff were required to provide daily ADL care and document refusals, but the record lacked that documentation except for one entry.
Three dependent residents did not receive their scheduled showers, with documentation showing missed or substituted bed baths and no evidence of refusals, despite staff claims. One resident with moderate cognitive impairment received only one shower since admission, another was not consulted about bathing preferences after wound healing, and a third, who preferred daily showers, had not received any since admission. Staff interviews confirmed the process for documenting refusals, but records did not reflect this.
A facility did not promptly address or document a grievance from a resident's family member about missing personal belongings after the resident's death. Despite the family member's repeated attempts to resolve the issue and staff acknowledgment of the concern, there was no inventory list, no record of communication, and no documentation in the grievance log as required by facility policy.
A resident did not receive prescribed migraine medication as ordered, with 19 doses unaccounted for and inconsistent documentation by nursing staff. The medication was not always stored securely, and pharmacy audits did not detect the discrepancy. The resident experienced significant pain due to the lack of medication, and the facility failed to properly investigate or account for the missing doses.
A resident with severe cognitive impairment was found restrained in a wheelchair with a gait belt by a COTA. The sitter assigned to supervise the resident used the gait belt to prevent the resident from getting up, claiming it was not fastened to the wheelchair. However, the COTA found it secured. Staff interviews confirmed the use of the gait belt as a restraint, violating the resident's right to be free from physical restraints.
A resident with severe cognitive impairment was found restrained in a wheelchair with a gait belt, violating their right to be free from physical restraint. The incident occurred when a sitter used the gait belt to prevent the resident from getting up, contrary to facility training. The resident was unharmed, and staff were subsequently educated on proper procedures.
The facility failed to provide necessary personal hygiene care for three residents, who were unable to perform activities of daily living independently. A resident with cerebral palsy was not receiving scheduled showers or oral care, and there was a lack of documentation for refusals. Another resident with chronic kidney disease often received bed baths instead of preferred showers, with no documentation of refusals. A third resident with multiple sclerosis expressed dissatisfaction with not receiving scheduled showers, and the clinical record lacked documentation of refusals or requests for alternative care.
Delay in Starting Antibiotics for Positive Wound Culture
Penalty
Summary
The facility failed to protect a resident from neglect by not providing antibiotics in a timely manner after a wound culture from the resident’s abdominal wound was positive for Escherichia coli. The resident was a cognitively intact female admitted after surgical aftercare for digestive system surgery, with diagnoses including diverticulitis, sepsis, and an open abdominal wound. Her care plan identified risk for skin breakdown related to a new ileostomy, indwelling catheter, and impaired mobility, and included monitoring for signs of infection or delayed healing. On 6/22/26, the wound care nurse observed the ileostomy site was soiled and the abdominal wound had excessive drainage, so a wound culture was obtained. The culture was received by the lab on 6/23/26 and resulted positive on 6/25/26. Nursing documentation showed the resident later complained that she believed her surgeon had prescribed antibiotics, but staff told her there was no antibiotic order noted and that the culture results were still waiting to be signed. The wound care nurse stated she assumed the resident knew what she was talking about and acknowledged that antibiotics were not started until 6/29/26, which was a delay. Physician orders for a midline and ertapenem were not placed until 6/28/26, with the antibiotic start date of 6/29/26. Interviews with the LPN, DON, ADON, administrator, and NP confirmed the positive culture had resulted days earlier and that nursing staff had not communicated the result to the MD or NP until 6/28/26. The DON and ADON stated the delay was not acceptable, and the NP said she should have been notified right away or at least the morning after the culture resulted.
Delayed Reporting of Positive Wound Culture
Penalty
Summary
The facility failed to ensure that abnormal lab results were promptly reported to the ordering practitioner for one resident. The resident was admitted with diagnoses including surgical aftercare following digestive system surgery, diverticulitis, sepsis, and an open abdominal wound. Her care plan identified risk for skin breakdown related to a new ileostomy, indwelling catheter, and impaired mobility, with instructions to observe for signs of infection or delayed healing and report them to the physician as needed. The resident was cognitively intact with a BIMS score of 15. On 6/22/26, the wound care nurse observed excessive drainage from the abdominal wound during dressing care, noted the ileostomy site was soiled, and notified the MD, who ordered a wound culture. The specimen was collected on 6/22/26, received by the lab on 6/23/26, and resulted positive for Escherichia coli on 6/25/26 at 12:14 p.m. Nursing documentation showed the resident later complained of pain and redness at the site, and on 6/27/26 the resident asked about antibiotics and was told the culture result was being reviewed and that the upcoming nurse should message the MD in the morning. The positive culture was not communicated to the NP until 6/28/26, when the wound culture result was reviewed and new orders were obtained for a midline/PICC and ertapenem. The resident stated she believed she was already receiving antibiotics and said she was told the culture was positive and placed in the file without follow-up to the doctor. Staff interviews confirmed the delay: the wound care nurse said she assumed the resident knew about antibiotics, the LPN said she did not know the culture was pending, the NP said she was first notified on 6/28/26 and should have been notified right away or the next morning, and the DON, ADON, and Administrator all confirmed the delay in reporting and treatment.
Unsecured Lighters Kept in Residents’ Rooms
Penalty
Summary
The facility failed to implement processes to prevent avoidable accidents by not ensuring the appropriate storage of ignition devices for four residents who smoked and kept lighters in their rooms. Surveyors observed Resident #37 remove cigarettes and a lighter from the front pocket of his gown and flick the lighter to produce a visible flame. Resident #67 stated he kept cigarettes in a box on his bedside table and knew he was not supposed to have a lighter, but kept one in his pocket; cigarettes were also observed on the bedside table and the outline of a lighter was seen in his sweatshirt pocket. Resident #118 was observed with a white lighter left unattended and unsecured on his bedside table while not in the room, and the lighter remained there during a later observation until the DON removed it. Resident #119 stated he kept cigarettes and a lighter with him, and cigarettes and a lighter were observed in the pocket of his shirt. The facility policy stated that residents with independent smoking privileges are not permitted to keep lighters, matches, or other smoking materials in their possession, and residents without independent smoking privileges may not keep smoking materials except when under supervision. Record review showed Resident #37 had diagnoses including unspecified Parkinsonism, primary progressive MS, generalized muscle weakness, major depressive disorder, anxiety disorder, and schizoaffective disorder, bipolar type, with a BIMS score of 12 indicating moderate cognitive impairment. Resident #67 had diagnoses including opioid dependence, sedative, hypnotic or anxiolytic dependence, anxiety disorder, generalized weakness, and repeated falls, and his smoking evaluation noted signs of confusion. Resident #118 had diagnoses including anxiety disorder, chronic respiratory failure with hypoxia, and protein-calorie malnutrition, and Resident #119 had diagnoses including syncope and collapse, alcohol dependence, nicotine dependence, COPD, generalized muscle weakness, and repeated falls. The report also noted that Resident #118’s room was near residents identified as wanderers or at elopement risk.
Unsafe Resident Smoking Practices and Ignition Device Storage
Penalty
Summary
The facility administration failed to provide effective oversight and failed to take appropriate actions to protect residents’ safety from foreseeable and avoidable incidents involving unsafe smoking practices and unsafe storage of ignition devices. The deficiency involved four of 17 resident smokers: Residents #37, #67, #118, and #119. The facility’s smoking policy stated that smoking/vaping materials were to be kept at the nurse’s station or other designated location, returned after each smoking session, and that residents may not maintain cigarettes, e-cigarettes, vaping materials, or lighters in their possession. Resident #37, who had diagnoses including primary progressive Multiple Sclerosis, generalized muscle weakness, major depressive disorder, anxiety disorder, and schizoaffective disorder, had a BIMS score of 12 indicating moderately impaired cognition. He told staff he usually smoked outside and kept cigarettes and a lighter in his bedside table, and he was observed removing cigarettes and a lighter from his gown pocket and flicking the lighter to produce a visible flame. Resident #67, who had diagnoses including opioid dependence, sedative, hypnotic or anxiolytic dependence, anxiety disorder, generalized weakness, and repeated falls, had previously been caught smoking in his room and stated he knew he was not supposed to do it but did not care. On the survey date, he said he kept a lighter in his pocket and cigarettes in a box on his bedside table, and cigarettes and the outline of a lighter were observed in his room. Resident #118, who had diagnoses including anxiety disorder, chronic respiratory failure with hypoxia, and protein-calorie malnutrition, was documented as a safe smoker with supervision, yet a white lighter was observed unattended and unsecured on his bedside table while he was not in the room and remained there later the same day. Resident #119, who had diagnoses including syncope and collapse, alcohol dependence, alcohol abuse with withdrawal, nicotine dependence, COPD, generalized muscle weakness, and repeated falls, said he kept cigarettes and a lighter with him, and cigarettes and a lighter were observed in the pocket of his shirt. The DON stated the facility had educated residents, did room sweeps from time to time, and could issue a 30-day discharge notice for repeat offenders, while the Administrator stated the smoking concerns had not been identified until the survey and that smoking supplies were taken and placed in a box when found.
Unsafe resident smoking practices and unsecured ignition devices
Penalty
Summary
The facility failed to implement and enforce its Resident Smoking Supervised and Unsupervised policy for 4 of 4 sampled residents reviewed for safe smoking, all of whom were smokers. The policy stated that residents who smoke are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, nicotine, lighters, matches, or other smoking/vaping articles in their possession, and that residents without independent smoking privileges may not have or keep any smoking/vaping materials except when under supervision. The facility’s smoking contract also stated that no tobacco paraphernalia or tobacco products are to be kept in resident rooms and that smoking materials found in a room would be removed and privileges revoked. Resident #37 was observed in his room with cigarettes and a lighter in his possession, including a lighter producing a visible flame. He told staff he kept cigarettes and a lighter in his bedside table and in the front pocket of his gown. His record showed an admission date of 9/27/24, a smoking evaluation dated 10/2/25, and no smoking-related care plan despite the evaluation. The MDS nurse stated smoking had been removed from his care plan in 2025 because he had quit smoking, but staff were informed of the observation of cigarettes and a lighter in his room and of him smoking in the designated smoking area. Resident #67 stated he kept a lighter in his pocket and cigarettes in a box on his bedside table, and staff observed cigarettes on the bedside table and the outline of a lighter in his sweatshirt pocket. His record showed an admission date of 9/3/25, a nursing note that he had been caught smoking in his room, and a care plan that noted smoking in room/educated but did not include how he would be monitored for compliance. Resident #118 had an unsecured white lighter on his bedside table while not in the room, and the DON later removed it; his care plan identified him as a safe smoker with supervision. Resident #119 stated he kept cigarettes and a lighter with him, and cigarettes and a lighter were observed in his shirt pocket; his care plan stated he must smoke with supervision, but the DON verified there was no smoking contract signed by him.
Insufficient nursing staff and delayed call light response
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by repeated delays in responding to call lights and resident requests for assistance. The report states that residents were waiting long periods for help, including more than 30 minutes, up to 1.5 hours, and in one account up to 2 hours. The facility assessment noted the need for an equitable distribution of workload among staff to prevent burnout and maintain high-quality care, yet multiple residents and staff described staffing shortages and delayed responses across shifts, especially at night. Resident #50, who had diagnoses including a displaced intertrochanteric fracture of the left femur, history of falling, muscle weakness, lack of coordination, and dementia, was observed moving toward the bathroom and pointing to it while seated in bed. Her roommate stated she could not get up on her own because she would fall. An RN said help would be obtained, the call bell was activated, and a CNA entered the room, turned off the call bell, and left without interacting with the resident. The call bell was later activated again and was not answered for several minutes before an LPN responded. Other residents reported similar delays and unmet needs. Resident #51 said staff did not come quickly when the call light was pressed and that his colostomy bag needed to be emptied; Resident #22 said staff forgot things and forgot about her; Resident #25 said nighttime staffing was a problem; Resident #30 said it could take up to 1.5 hours for help to use the bathroom; Resident #133 said call lights could take longer than 30 minutes; Resident #140 said it could take up to 2 hours for help; and Resident #52 said she had to call the front desk because no one answered her call light and that she had waited 6 hours in urine. During resident council, residents said there were usually not enough CNAs, that they waited an hour or two for needs to be met, and that if a CNA not assigned to them answered the call light, they were told to wait for their assigned CNA. Staff also reported assignments of 14 to 19 residents per CNA and said there were not enough CNAs to care for residents who required 2 or more staff for assistance.
Medications Left Unsecured at Bedside
Penalty
Summary
The facility failed to ensure medications were secured, locked, and inaccessible to unauthorized staff, residents, and visitors, or under direct observation of authorized staff for 4 of 4 residents observed with medications left at bedside. Facility policy titled Medication Administration, revision date 10/2023, stated medications are to be administered by licensed nurses or other legally authorized staff in accordance with professional standards of practice, and compliance guideline #15 indicated to observe resident consumption of medication. On 3/2/2026, a red tablet was observed on Resident #67's bedside table, and the resident picked it up and set it back down, stating it was his iron pill and that sometimes he did not take it. An inhaler was observed on Resident #16's bedside table, and the resident said staff leave it on her tray table in the morning and return later to pick it up. Two medication cups with one white round tablet in each were observed on Resident #118's bedside table, and the resident said staff just give him the cup of medications and he thought the pills might be melatonin and sometimes he did not take it. Resident #132's bedside table had a medication cup with 2 round tablets inside, and the resident said he thought it was his TUMS medication left for him to take later when he was ready. The DON stated no resident should have medications at the bedside and that no residents were care planned to self-administer medications. An LPN later stated she had left Resident #132's TUMS for him to take later when he was ready, and the DON stated a nurse should not leave medications unattended in a resident's room.
Failure to Respond to Resident Council Grievances
Penalty
Summary
The facility failed to respond to and follow up on grievances and concerns brought forward by the Resident Council for 2 of 4 Resident Council meeting minutes reviewed, specifically the November and December 2025 meetings. The facility’s Resident Right-Grievances policy stated that the resident has the right to prompt efforts by the facility to resolve grievances and that written grievance decisions should include the date received, a summary of the grievance, steps taken to investigate, pertinent findings or conclusions, whether the grievance was confirmed, any corrective action taken or to be taken, and the date the written decision was issued. At the Resident Council meeting on 3/3/26, residents reported long waits for care, staffing problems, not enough CNAs, and waits of an hour or two for needs to be met. They also said that if a CNA not assigned to them answered the call light, they were told to wait until their assigned CNA came, and they reported long wait times for pain medications and showers. The November and December 2025 Resident Council minutes documented that call light response was too slow, mainly at night, with staff in-serviced on call light response times, but the outcome remained not resolved and action needed. January and February 2026 minutes also did not show the call light concern as resolved. The Resident Council President stated there had been no improvement with staffing or call light response, and the Social Services Director confirmed the concerns and that there was no documentation the call light concerns were resolved.
Failure to Promptly Resolve and Follow Up on Resident Grievances
Penalty
Summary
The facility failed to ensure prompt resolution and follow-up for grievances for 3 residents who reported slow call light response times. The Resident Right-Grievances policy stated the facility would make prompt efforts to resolve grievances and that written grievance decisions should include the date received, a summary of the grievance, steps taken to investigate, findings or conclusions, whether the grievance was confirmed, corrective action taken or to be taken, and the date the decision was issued. The grievance log showed one resident filed grievances for call light response time on multiple occasions, and the resident stated staff were not coming, that it took about an hour on average for staff to respond, that waits had lasted up to 3 hours, and that nothing had been resolved. The resident also said she needed assistance with perineal care and emptying of her urinary catheter and that after submitting grievances she never saw anyone again. Her BIMS score was 15, indicating she was cognitively intact. The grievance log also showed call light grievances for two other cognitively intact residents, both marked as resolved, but both residents stated the problem continued and that no one followed up with them after they filed grievances. One resident said he still waited over an hour for care related to his amputation and had given up because nothing was changing. Another resident said no one ever came back to discuss anything after she filed her grievance about slow call light response times. The DON stated she investigated grievances and educated staff, and the Social Services Director stated there was no documentation that the call light concerns from resident council were resolved and that no one followed up or resolved the grievances according to documentation.
PASRR assessments were inaccurate and Level II screenings were not completed
Penalty
Summary
The facility failed to ensure Level I PASRR assessments were completed accurately and failed to complete Level II PASRR screenings as required for two residents reviewed. Resident #50 was admitted with diagnoses of major depressive disorder and severe cognitive impairment, but the PASRR completed on admission did not document major depressive disorder or a disorder resulting in functional limitations in major life activities, and no Level II PASRR was completed. Resident #8 was admitted with diagnoses of bipolar disorder and was cognitively intact, but the PASRR completed for that resident did not document bipolar disorder or a disorder resulting in functional limitations in major life activities, and no Level II PASRR was completed. During interviews, the Director of Admissions stated that the Unit Manager and DON review admission packets for PASRR and clinical documentation and that PASRRs had appeared incorrect because diagnoses were not listed correctly. The Unit Manager said she reviews PASRRs for all new admissions to ensure they are complete and nothing is missing, and the DON stated the facility’s policy is to ensure PASRRs are completed correctly, not just that they are done. The DON reviewed both residents’ records and stated that each resident had a diagnosis not documented on the Level I PASRR and should have had a Level II PASRR. The Director of Social Services also reviewed the records and stated that Resident #8 possibly should have had a Level II PASRR and that Resident #50 should have had a Level II PASRR.
Failure to Maintain Resident Grooming and Nail Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain personal grooming and hygiene for Resident #132, who was cognitively intact with a BIMS score of 13 and required assistance with ADLs. On 3/2/26, the resident was observed lying in bed wearing a hospital gown with fingernails on both hands uneven and approximately 3/4 of an inch long, with dark brown substance under each nail. His hair and beard were also observed to be uncombed and long. The resident stated his fingernails had not been trimmed in a long time and that he had asked staff several times over the past few months to trim them. Record review showed the resident’s ADL form instructed staff to encourage him to have his nails cut because he preferred longer nails, but January, February, and March 2026 ADL documentation did not show that the CNA documented any refusal to have his fingernails cut. The RN UM stated staff were required to complete daily ADL care, including trimming fingernails unless the resident was diabetic, and that refusals should be documented and reported to the nurse. The POA stated she had asked staff since December 2025 and again on the resident’s birthday to trim his fingernails and beard, but staff had not honored the request or informed her that he was refusing. The DON confirmed the resident’s care plan noted he liked long nails, but staff were required to encourage nail trimming, and she confirmed the chart lacked documentation of refusal except on 2/2/26 and lacked documentation of routine encouragement.
Failure to Provide Scheduled Showers and Proper Documentation for Dependent Residents
Penalty
Summary
The facility failed to ensure that three dependent residents received their scheduled showers, as evidenced by clinical record reviews, resident and staff interviews, and documentation inconsistencies. One resident, who required partial assistance with bathing and had moderate cognitive impairment, reported only receiving one shower since admission despite being scheduled for showers twice weekly. Documentation showed missed showers, with 'Not Applicable' or 'bed bath' recorded instead, and no evidence that the resident refused care, contrary to staff claims. Another resident, who had a history of abdominal surgery and a wound vac, was documented as preferring bed baths twice a week. However, interviews revealed that the resident was not asked about shower preferences and expressed confusion about not being offered showers, which he had always taken prior to admission. The wound vac was discontinued and the wound healed, yet the resident continued to receive only bed baths without reassessment of bathing preferences or needs. A third resident, with intact cognition and a preference for regular showers, reported not receiving a shower since admission and expressed distress over not having his hair washed for two weeks. Documentation indicated only bed baths were provided, with no record of showers being given or refused. Multiple CNAs confirmed the process for documenting refusals, but there was no evidence in the records that refusals occurred, indicating a lack of adherence to scheduled bathing and proper documentation.
Failure to Address and Document Family Grievance Regarding Missing Resident Belongings
Penalty
Summary
The facility failed to promptly address and document a grievance raised by the family member of a deceased resident regarding missing personal belongings. The resident's niece-in-law reported that after the resident's death, she requested the facility to store the resident's possessions until she could retrieve them. Upon her arrival, she found that many items were missing, and despite searching with the Social Worker and contacting the interim Administrator multiple times, she did not receive a follow-up or resolution. There was no inventory list in the resident's clinical record, nor any documentation of communication with the family about the disposition of the possessions. Interviews with facility staff revealed inconsistent practices regarding the inventory and storage of resident belongings, with some staff unaware of the contents or procedures followed after the resident's death. The Social Worker and interim Administrator both acknowledged the family member's concerns but could not provide evidence of a formal grievance being logged or investigated. Review of the facility's grievance log confirmed the absence of documentation related to the grievance or steps taken to resolve it, contrary to the facility's own grievance policy requirements.
Failure to Account for and Safeguard Resident Medication
Penalty
Summary
The facility failed to properly identify, investigate, and prevent the misappropriation of a resident's physician-prescribed medication. A review of records showed that a resident had an active order for Fioricet, a medication for migraine headaches, with 30 capsules delivered by the pharmacy. However, only 11 capsules were documented as administered over a ten-day period, leaving 19 capsules unaccounted for. The resident reported not receiving the medication for a period of time, experiencing significant pain as a result. The facility's grievance log and investigation documentation did not accurately reflect the medication delivery and administration timeline, and the missing doses were not accounted for in the records. Further review and interviews revealed that the medication was not consistently stored in a double-locked drawer, and pharmacy audits did not include spot checks for this medication. The pharmacy consultant confirmed that Fioricet is not a controlled substance and therefore was not required to be double-locked, but acknowledged that one of its ingredients is a barbiturate. The facility's corporate DON suggested that the issue may have been due to documentation errors, as nurses failed to sign out the medication approximately 20 times. No additional packages of the medication were found, and the missing doses remained unaccounted for.
Resident Restrained with Gait Belt in Wheelchair
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraints. The incident involved a resident who was re-admitted to the facility with severe cognitive impairment and other medical conditions. During an incident, the resident was found in his wheelchair with a gait belt around his abdomen, secured to the wheelchair. The Certified Occupational Therapy Assistant (COTA) discovered this when she went to retrieve the resident for therapy. The investigation revealed that the resident's sitter, who was assigned to provide one-on-one supervision, used the gait belt to prevent the resident from getting up, as he was attempting to do so repeatedly. The sitter claimed she was holding the gait belt and did not attach it to the wheelchair, but the COTA found it secured. Interviews with staff members, including the Social Services Director and Assistant Staff, confirmed the use of the gait belt as a restraint. The Social Services Director mentioned that all staff had been educated on abuse and neglect training, and he had never witnessed a staff member restrain a resident. The Assistant Staff reported the incident to her supervisor immediately upon noticing the restraint. The sitter involved in the incident stated she had never seen the gait belt in the room before and was holding it to prevent the resident from falling. She was sent home during the investigation and later received training on abuse and neglect, emphasizing not to use gait belts as restraints. The facility concluded that the sitter used the gait belt to keep the resident from getting up until the COTA returned, which constituted a failure to protect the resident's rights.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws. F 604- Right to Be Free from Physical The gait belt was immediately removed from the resident and chair by the certified assistant (COTA). The COTA immediately notified her supervisor, the director of rehabilitation (DOR), who immediately reported to the facility Administrator. The Administrator immediately spoke to the staff member and relieved her of duty until further investigation is completed. Resident was assessed and found to have no injuries nor affected by this use of the gait belt. - 100% audit of all residents in the facility to assess if gait belts were being utilized anywhere else with no observations of use were observed. - Ten residents were interviewed by Social Services to determine if the staff treated them with dignity and respect and if they had ever been in a situation that made them feel uncomfortable, do they feel safe? 100% of the interviewees had no negative responses. - Ten staff members were interviewed to see if they had ever observed a staff member, family member, or another resident restrain a resident. 100% of the responses received no indication that it had ever been observed. 100% Staff education completed by on Neglect and Misappropriation and post-test administered to ensure comprehension or received education that gait belts cannot be used as a form of restraint. As part of a systematic change, Nursing Home Administrator/Designee while on rounds will observe for the use of gait belts. Education was provided to Department Heads on the addition of observation for the use of gait belts and completed on round sheets. Round sheets will be turned into the Administrator daily Monday-Friday indicating if anything is observed that needs to be evaluated as a possible restraint so that immediate action can be taken. Weekend Supervisor will complete facility rounds observing each room looking for any item that could be identified as a restraint. If found, proper notifications to be completed if possible are observed. The rounds will be completed daily for a period of 4 weeks, then twice for one month, and then weekly for one month until substantial compliance is met. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Resident Restraint Violation
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraint. The incident involved a resident who was re-admitted to the facility with a diagnosis that included aphasia, affecting their ability to speak. The resident's cognitive assessment indicated severe impairment. During an incident, the resident was found in their room, in a wheelchair, with a gait belt around their abdomen secured to the wheelchair. The Certified Occupational Therapy Assistant (COTA) discovered this situation and reported it to the Administrator. The resident was assessed and found to have no injuries. The investigation revealed that the resident had been assigned a sitter for one-to-one supervision. The sitter reported that the resident kept getting up, and she used the gait belt to keep the resident in the wheelchair until another staff member returned. The sitter claimed she did not attach the gait belt to the wheelchair, but the COTA observed it secured to the chair. Interviews with staff indicated that the use of the gait belt was not in line with the facility's training on restraint and neglect. The staff involved were educated on the proper procedures following the incident.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws. Tag 0024 - Right to Be Free from, etc. The gait belt was immediately removed from the resident and chair by the certified assistant (COTA). The COTA immediately notified her supervisor, the director of rehabilitation (DOR), who immediately reported to the facility Administrator. The Administrator immediately spoke to the staff member and relieved her of duty until further investigation is completed. Resident was assessed and found to have no injuries nor affected by this use of the gait belt. - 100% audit of all residents in the facility to assess if gait belts were being utilized anywhere else with no observations of use were observed. - Ten residents were interviewed by Social Services to determine if the staff treated them with dignity and respect and if they had ever been in a situation that made them feel uncomfortable, do they feel safe? 100% of the interviewees had no negative responses. - Ten staff members were interviewed to see if they had ever observed a staff member, family member, or another resident restrain a resident. 100% of the responses received no indication that it had ever been observed. 100% Staff education completed by on Neglect and Misappropriation and post-test administered to ensure comprehension or received education that gait belts cannot be used as a form of restraint. As part of a systematic change, Nursing Home Administrator/Designee while on rounds will observe for the use of gait belts. Education was provided to Department Heads on the addition of observation for the use of gait belts and completed on [date]. Round sheets will be turned into the Administrator daily Monday-Friday indicating if anything is observed that needs to be evaluated as a possible violation so that immediate action can be taken. Weekend Supervisor will complete facility rounds observing each room looking for any item that could be identified as a violation. If found, proper notifications to be completed if possible. Rounds will be completed daily for a period of 4 weeks, then twice for one month, and then weekly for one month until substantial compliance is met. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Provide Scheduled Showers and Document Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for three residents who were unable to perform activities of daily living independently. Resident #899, diagnosed with cerebral palsy and other conditions, was observed with unshaven facial hair and reported not receiving scheduled showers or oral care. Despite being dependent on staff for personal hygiene, there was a lack of documentation indicating that Resident #899 refused care, and staff interviews revealed inconsistencies in the provision of care. Resident #800, with chronic kidney disease and diabetes, preferred showers but often received bed baths instead. The clinical record lacked documentation of any refusals or requests for bed baths, and staff interviews suggested that convenience sometimes dictated the type of care provided. Similarly, Resident #7, diagnosed with multiple sclerosis, expressed dissatisfaction with not receiving scheduled showers, and the clinical record did not document any refusals or requests for alternative bathing methods. The facility's policy required residents unable to perform activities of daily living to receive necessary services to maintain hygiene. However, the documentation and staff interviews indicated a failure to consistently provide scheduled showers and document refusals or alternative care methods. This deficiency in care and documentation affected the residents' personal hygiene and did not align with the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Naples
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chateau At Moorings Park, The | 1.6 mi | ★★★★★ | 1 | 0 |
| Premier Place At The Glenview | 2.7 mi | ★★★★★ | 3 | 0 |
| Adviniacare At Naples | 4.4 mi | ★★★★★ | 4 | 0 |
| Woodside Health And Rehabilitation Center | 5.2 mi | ★★★★★ | 5 | 0 |
| Gardens At Terracina Health & Rehabilitation | 5.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Naples Health And Rehabilitation Center.
100% money-back within 48 hours.
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.