Adviniacare at Naples

Inspectors wroteBased on observation, clinical record review, review of facility's policies and procedure, resident and staff interviews, and record review the facility failed to provide appropriate care and services to 2 (Residents #47 and #48) of 2 residents receiving intravenous antibiotics through peripherally inserted central catheters (PICCs).

Inspectors wroteBased on observation and interview, 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.

Inspectors wroteBased on record review, facility policy review, resident, family member and staff interviews, the facility failed to ensure dental services were appropriately coordinated for 1 (Resident #39) of 2 residents reviewed for dental services. The facility failed to maintain documentation of dental consultations in the medical record, failed to follow up on recommendations made during a dental consultation and failed to ensure the Resident was informed of financial responsibility and payment options for recommended dental services. These failures have delayed necessary dental care and impeded the Residents ability to make informed decisions regarding treatment and associated costs.

Inspectors wroteBased on record review and interview, the facility failed to have a binding arbitration agreement for 3 (Residents #1, #20 and #28) of 3 residents reviewed that explicitly states that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. This has the potential to affect all residents residing in the facility. Review of the facility's binding arbitration agreement (not dated) revealed that it did not state that signing this agreement is not a requirement for admission. The signature page of the document states the undersigned acknowledge that each of them has read all six (6) pages of this agreement . [...]

Inspectors wroteBased on observation, record review, review of facility's policies and procedures and staff interviews, the facility failed to adequately supervise 3 (Residents #1, #2 and #3) of 3 cognitively impaired residents to prevent incidents of unsafe wandering and elopement. On 12/9/24 at 2:15 p.m., Resident #1, who had a diagnosis of Dementia, severe cognitive impairment and history of attempted elopement exited the facility through the front door and set off the alarm. Staff turned off the alarm without verifying the whereabouts of residents with wander alarm bracelets. On 12/9/24 at approximately 2:17 p.m., a staff member who was outside on break, saw the resident wandering unsupervised in the parking lot and returned him to the facility. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility administration failed to utilize its resources effectively to ensure the safety of 3 (Residents #1, #2, and #3) of 3 cognitively impaired residents and prevent multiple incidents of unsafe wandering and elopement. Resident #1 had severe cognitive impairment, was at risk for elopement and used a wander alarm bracelet. On 12/9/24 at 2:15 p.m., staff did not appropriately respond to the door alarm when Resident #1 exited the facility. On 12/9/24 at approximately 2:17 p.m., a staff member who was outside on her break found the resident wandering in the parking lot unsupervised and returned him to the facility. Resident #2 had severe cognitive impairment, was at risk for elopement and used a wander alarm bracelet. On 2/24/25 at 4:30 p.m., staff did not adequately supervise the resident. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to thoroughly investigate elopement incidents for 3 (Residents #1, #2, and #3) of 3 cognitively impaired residents reviewed for elopement and failed to implement appropriate systemic corrective actions to prevent further incidents of unsafe wandering and elopement of mobile and confused residents. On 12/9/24 at 2:15 p.m., Resident #1 who had severe cognitive impairment and wore a wander alert bracelet exited the facility, setting off the door alarm. Staff did not appropriately respond to the alarm. A staff member who was outside on her break found the resident wandering unsupervised in the parking lot and brought him back. On 2/25/25 at 4:30 p.m., staff did not adequately supervise Resident #2 who had severe cognitive impairment and wore a wander alert bracelet. [...]

Inspectors wroteBased on record review, review of facility policies and procedures, resident and staff interviews the facility failed to follow the established plan of care for safe transfer, resulting in an avoidable fall and fall related major injury for 1 (Resident #3) of 3 residents reviewed.

Inspectors wroteBased on staff interviews, record review and facility policy review the facility failed to report an incident of possible neglect to the State Survey Agency related to a medication error for a critical medication for 1 (Resident #1) of 3 residents reviewed.

Inspectors wroteBased on observation, record review, facility policy review, resident and staff interviews and medical record and facility policy review, the facility failed to protect residents' rights to be free from neglect by failing to provide a safe environment for 2 (Residents #243 and #20) of 5 residents reviewed for avoidable falls and accidents.

Inspectors wroteBased on observation, record review, facility policy review, resident and staff interviews and medical record and facility policy review, the facility failed to implement adequate supervision to prevent accidents for 2 (Residents #20 and #243) of 5 residents reviewed for accidents.

Inspectors wroteBased on staff and resident interview, medical record review, and review of facility policies, the facility failed to have documentation of a thorough investigation for 1 (Resident #243) of 1 resident reviewed for elopement.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the baseline care plan was developed and implemented for 1(Resident #196) of 6 baseline care plan reviewed to ensure it includes the instructions/interventions needed to provide effective and person-centered plan of care that meet the professional standards of quality of care.

Inspectors wroteBased on observation interview and record review the facility failed to ensure they had a physician's order for the continuation, flushing and dressing change of an intravenous peripheral catheter (IVPC) for 1 Resident (#197) of 1 resident reviewed with an IVPC as related to facility's policy IVPC care and in accordance with the professional standard of care for IVPC.

Inspectors wroteBased on facility policy review, employee file review and interview it was determined that the facility failed to ensure infection control management staff had the proper infection prevention education and training as required.

Inspectors wroteBased on staff and resident interviews, clinical records review, and facility policy review the facility failed to assist in obtaining routine or emergency dental care for 1 (Resident #2) complaining of chronic dental pain of 12 sampled residents reviewed for dental.

Inspectors wroteBased on observation, record review, review of facility's policy and procedure, and staff interview, the facility failed to have documentation of consistent monitoring of weight, meals, and prescribed supplement intake to evaluate the effectiveness of nutritional interventions for 3 (Resident #16, #9, and #174) of 5 sampled residents identified at risk for impaired nutrition and weight loss.

Inspectors wroteBased on clinical record review, review of facility policy and procedure, and resident and staff interviews, the facility failed to provide the necessary care and services to maintain the urinary catheter for 1 (Resident #323) of 1 resident reviewed for indwelling catheter care.

Inspectors wroteBased on observation, record review, policy review, staff and resident interviews, the facility failed to ensure 1(Resident #323) of 12 residents reviewed for accidents was assessed for alternative interventions prior to the use of grab bars. This had the potential to have grab bars installed when alternatives with less chance of negative consequences could be utilized.

Inspectors wroteBased on observation resident and staff interview, the facility failed to honor food preferences for 1 (Resident #177) of 3 residents reviewed. This has the potential for complications if allergies to certain foods are served.

Inspectors wroteBased on observation, review of policies and procedure and staff interview, the facility failed to ensure the hand washing sink in the kitchenette was functioning for staff use. The failure to maintain the function of the sink had the potential for water borne pathogens to grow in the standing water. The facility failed to properly date and label resident food items stored in the facility kitchenette refrigerator. The failure to date, label and dispose of expired foods placed residents at risk for developing food borne illnesses.