Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Woodside Health And Rehabilitation Center during CMS and state inspections, most recent first.
Delayed response to resident call lights and toileting assistance. Two residents were observed waiting for help while staff passed by or failed to respond promptly. One resident with urinary and bowel incontinence and intact cognition said call lights could take hours to be answered and that staff did not come when he needed his urinal emptied or after a bowel movement. Another resident with bowel and bladder incontinence and impaired cognition was found unclothed and holding a soiled brief while waiting in the bathroom, and said staff often turned off the call light without helping and that he had been waiting a long time.
Failure to Address Resident Council Concerns About Call Light Response: The Resident Council repeatedly raised concerns that call lights were not answered promptly, especially on weekends and overnight, and that CNAs were turning off call lights without entering the room or following through. Meeting minutes documented ongoing complaints about call light response times, including waits of 30 to 45 minutes, but the facility had no documented response to the repeated grievances. The Resident Council President reported staff would reach in and shut off the call light, and the Social Service Director acknowledged the concerns but had no documentation showing how they were addressed.
The facility failed to have a designated licensed nurse serving as charge nurse on the 11 p.m. to 7 a.m. shift. Multiple LPNs stated there was no charge nurse assigned on nights and that staff would call the DON for problems or emergencies. Review of the 11-7 nurse assignments showed no designated charge nurse for the night shift, and the DON confirmed the facility did not have an assigned charge nurse as required.
Two residents experienced significant medication errors related to missed and delayed meds. A cognitively intact resident with arthritis, COPD, anxiety, and a hip replacement repeatedly did not receive ordered eye ointment because it was on order from pharmacy, and another resident ordered IV Cubicin for osteomyelitis had multiple missed doses when the med was not available from pharmacy; one note also showed the MD was not notified of a missed dose.
An LPN left two medication carts unlocked and unattended on a hallway, with one cart holding prefilled NS syringes, powdered cefazolin, and a 50 mL NS bag, and the other cart containing residents' medications. The LPN confirmed the items and carts were unsecured, and another LPN later verified one cart remained unlocked and unattended. The ADON and Administrator were informed of the observation.
A resident with a neurogenic bladder experienced abdominal pain and bleeding, leading to the replacement of a 16 French urinary catheter with a 20 French catheter. Although the attending physician was notified of the resident's condition and ordered diagnostic tests and interventions, there was no documented physician order for the catheter size change. Both the RN who performed the procedure and the DON confirmed the absence of the required order.
The facility failed to maintain a clean, safe, and comfortable environment, with cluttered hallways and damaged resident rooms and bathrooms. Residents reported bumping into items in the hallways, and the administrator acknowledged the need for repairs, citing ongoing plumbing issues and a new Maintenance Director yet to start.
The facility failed to resolve grievances related to the call light system, affecting two residents who experienced delays in staff response. One resident reported inconsistent response times, while another faced delays due to a broken call bell system, requiring her to walk to the nurses' station for assistance. The facility used a temporary wireless system that required residents to carry a button, which was ineffective if not carried, especially in the bathroom.
A resident in a long-term care facility missed multiple doses of Lactulose, an ammonia-reducing medication, due to a failure to follow physician orders. The resident, awaiting a liver transplant, was admitted with a prescription for Lactulose four times daily. However, the MAR showed missed doses and an improper discontinuation of the medication without a physician's order. The resident's family raised concerns, and the resident was eventually removed from the facility against medical advice after becoming lethargic with high ammonia levels.
Delayed Response to Resident Call Lights and Toileting Assistance
Penalty
Summary
The facility failed to respond timely to residents’ requests for assistance for 2 residents observed. During a tour, a call light for one room was observed on while LPN staff and a CNA passed by, and the call light remained unanswered until the Social Service Director answered it about 17 minutes later. In another observation, a resident was heard yelling loudly for help for approximately 15 minutes, with no staff observed in the hallway and the call light not on. Resident #750 had diagnoses including history of falling and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS showed dependence on staff for toilet hygiene and transfers, frequent urinary incontinence, and bowel incontinence, and the resident scored 15 on the BIMS, indicating intact cognition. In interview, the resident said staff did not come at night, that call lights could take hours to be answered, and that he could not get out of bed on his own. He said he kept a urinal on the table because it filled quickly, and when he needed it emptied or had a bowel movement, staff did not come, causing him to yell for help. Resident #799 was observed with an emergency call light on and beeping while staff walked past the room. The resident was later found sitting in a wheelchair in front of the toilet with no clothes on and holding a soiled incontinent brief, stating he needed help. The call light was turned off by an RN while the resident remained in the bathroom waiting for assistance, and the resident later said no one had come to help, he had been waiting a long time, and he had been yelling loudly for help. His record showed chronic kidney disease stage 3, type 2 diabetes mellitus, hypertensive heart disease, frequent bowel and bladder incontinence, substantial to maximum assistance needed for toilet transfers, and moderately impaired cognition.
Failure to Address Resident Council Concerns About Call Light Response
Penalty
Summary
The facility failed to act promptly on repeated grievances raised by the Resident Council regarding call light response time and call lights not being kept within reach. Resident Council meeting minutes from August 2025 through November 2025 documented ongoing complaints that call lights were not answered promptly, especially on weekends and overnight, that CNA staff needed education on answering call lights, and that some residents experienced wait times of 30 to 45 minutes. The minutes also documented concerns that CNA staff were turning off call lights without coming into the room and not following through on what they said they would do. The concerns were repeatedly recorded in Council meetings on multiple dates, including requests for staff education and questions about whether more mobile residents should help locate weekend CNAs, but the facility did not document a response to address the issues. During an interview, the Resident Council President stated staff did not come into the room to answer the call light and instead reached in and turned it off, and she said she went to the nurse's station to look for help because she could walk. The Social Service Director acknowledged that call lights were a concern and stated she did not have documentation showing how the facility addressed the repeated concerns raised by the Resident Council from August through November 2025.
No Designated Charge Nurse on Night Shift
Penalty
Summary
The facility failed to have a designated licensed nurse serving as charge nurse on the 11:00 p.m. to 7:00 a.m. shift. During interviews on 11/12/25, an LPN stated there was no charge nurse assigned to the night shift and said there had never been an assigned charge nurse on nights, adding that staff would contact the DON if an emergency occurred. Another LPN confirmed there was no designated charge nurse on duty and said there never is a designated licensed nurse to serve as charge nurse for the night shift, with the DON called for problems. A third LPN also stated there was no charge nurse assigned on the night shift and that emergencies were handled by calling the DON. Review of the 11-7 shift nurse assignments from 11/5/25 through 11/12/25 showed no designated charge nurse assigned for the night shift. On 11/13/25, the DON confirmed the facility did not have an assigned charge nurse as required on the 11:00 p.m. to 7:00 a.m. shift and stated staff just call the DON.
Significant Medication Errors Due to Missed and Delayed Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for 2 of 4 residents sampled. Facility policy required medication reorders, changes, and discontinuations to be communicated to the pharmacy in a standardized manner, including clear resident identification and refill information. Resident #900, who was cognitively intact and had diagnoses including osteoarthritis, right hip replacement, COPD, and generalized anxiety disorder, reported that her eye ointment had not been available for several days. Her record showed orders for Pataday Ophthalmic Solution 0.7% for both eyes, but the MAR documented repeated missed administrations because the medication was on order from pharmacy on multiple dates across September, October, and November before it was discontinued. Resident #800 reported receiving IV antibiotics every other day but stated the medication was often not available because it had not come in from pharmacy. The physician order showed Cubicin Solution 500 mg IV every 48 hours for osteomyelitis. The MAR documented missed administrations, including doses not given because the medication was awaiting pharmacy delivery, and one note stated the physician was not notified of a missed dose. Additional documentation showed the medication was reordered and the schedule was changed after a missed dose, but the record still reflected another missed administration while awaiting pharmacy supply.
Unsecured Medication Carts and Drugs Left Unlocked on Hallway
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments when not in use in 1 of 3 hallways observed, specifically the [NAME] Unit Hallway. Facility policy titled Medication Storage and Labeling, revised 1/2024, stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner and kept in locked compartments, with access limited to persons authorized to prepare and administer medications. During the initial tour, surveyors observed two medication carts on the [NAME] Unit Hallway. One cart had two prefilled syringes of Normal Saline Solution 0.9%, a bottle of powdered Cefazolin 2 grams for Resident #700, and a 50 milliliter bag of normal saline left unlocked and unattended on top of the cart. An LPN confirmed the items were left unattended and unlocked and stated they should have been locked in the medication cart. A second medication cart about 10 feet away was also observed unlocked and unattended. The cart contained residents' medications, and the LPN confirmed it was unlocked and unattended, stating that other nurses use the cart too. The LPN then walked away, leaving the cart unlocked and unattended, and another LPN later verified it remained unlocked and unattended. The ADON and Administrator were informed of the observation but did not provide additional information or explanation.
Lack of Physician Order for Urinary Catheter Change
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician's order was documented for the insertion of a size 20 French urinary catheter for a resident with a neurogenic bladder. The resident was admitted with an indwelling urinary catheter size 16 French, as documented in the hospital discharge records. On a subsequent date, the resident experienced new abdominal pain, bleeding, and severe spasms, prompting the attending physician to be notified and to order diagnostic tests and interventions, including flushing and irrigation of the urinary catheter. Despite these interventions, nursing progress notes indicated that the 16 French catheter was replaced with a size 20 French catheter. However, a review of the physician's orders did not reveal any documentation authorizing this change. The registered nurse who performed the catheter replacement stated that he believed he had communicated with the physician but confirmed there was no documented order for the procedure. The Director of Nursing also verified the absence of a physician's order for the catheter change.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for its residents, as evidenced by observations and interviews conducted during a survey. Common hallways were cluttered with wheelchairs, walkers, supply carts, water carts, mechanical lifts, and mattresses, creating obstacles for residents. The flooring in these hallways was in poor condition, with cracked, missing, or stained tiles, and there were multiple areas of peeling wallpaper and damaged cove base. Additionally, several resident bathrooms exhibited black bio-growth on walls and ceilings, and numerous resident rooms and bathrooms had issues such as peeled or missing paint, holes in plaster, scrapes on walls, damaged cove base, missing caulk around toilets, cracked or missing tiles, and brown substances on toilets. Interviews with residents revealed that the clutter in the hallways posed a risk of physical harm, particularly for those with visual impairments, as they had bumped into the items. Residents also expressed concerns about the state of disrepair in their rooms, with one resident noting that the damage had been present for a significant period. The facility's administrator acknowledged the need for repairs and mentioned that a new Maintenance Director had been hired, but the repairs had not yet been completed. The administrator also noted that the facility had been experiencing ongoing plumbing issues due to root intrusion, which had not been resolved, and that maintenance personnel from other facilities were being brought in to assist with repairs.
Deficiency in Call Light Response
Penalty
Summary
The facility failed to ensure the resolution of residents' grievances related to the call light system, affecting two residents who reported issues with staff not promptly responding to their requests for assistance. Resident #6 expressed that the response time varied depending on the staff on duty, and at times, staff did not respond at all, forcing him to go to the nurses' station for help. Resident #5 reported that the call bell system had been broken for some time, and a temporary system was in place, which resulted in delays of up to 45 minutes before she had to walk to the nurses' station herself. She noted her ability to walk as fortunate, unlike other residents who might not be able to do so. The grievance log and Resident Council meeting minutes revealed ongoing concerns about the call light system and response times from January to June 2024. The facility administrator acknowledged that a wireless call bell system was in place on the 300 hall, requiring residents to carry a red button to alert the nurses' station. However, if residents did not have the button with them, such as when using the bathroom, they could not request assistance due to the old system's enunciator panel being broken and sent out for repair.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering multiple doses of Lactulose, an ammonia-reducing medication, as per the physician's order. The resident, who was admitted following a hospitalization for a liver workup and was on a waitlist for a liver transplant, had a physician's order to take Lactulose four times daily. However, the Medication Administration Record (MAR) indicated that the resident did not receive any medications on the day of admission and missed six out of eight doses of Lactulose over the following two days. The failure to administer the medication as ordered was not documented, and there was no physician's order to discontinue the medication, although it was noted as discontinued in the MAR. The resident's family raised concerns about the medication dosing, prompting a call to the physician, who confirmed the original order was correct and had not been changed. The resident became lethargic and difficult to arouse, with a high ammonia level recorded, leading the family to remove the resident from the facility against medical advice. Interviews with the facility's Administrator and Director of Nursing revealed a lack of awareness of the missed doses and improper discontinuation of the medication. The physician confirmed he did not issue an order to discontinue the Lactulose and was unaware of the missed doses until contacted to restart the medication.
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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) |
|---|---|---|---|---|
| Gardens At Terracina Health & Rehabilitation | 2.3 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Lely Palms | 2.5 mi | ★★★★★ | 0 | 0 |
| Oakton Place Health And Rehabilitation At The Arli | 4 mi | ★★★★★ | 0 | 0 |
| Naples Health And Rehabilitation Center | 5.2 mi | ★★★★★ | 14 | 3 |
| Chateau At Moorings Park, The | 6.5 mi | ★★★★★ | 1 | 0 |
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