Naples Health and Rehabilitation Center

Inspectors wroteBased on record review, staff interviews, resident interview and observation, the facility failed to protect the resident's right to be free from neglect by failing to provide antibiotics in a timely manner to 1 (Resident #1) of 4 residents reviewed. The failure to provide the necessary care, antibiotics for a positive wound culture, to avoid physical harm placed the resident at risk for sepsis, a life-threatening response to an infection.

Inspectors wroteBased on record review, facility policy review, and staff interviews the facility failed to ensure staff notified providers of abnormal lab results in a timely manner for 1 (Resident #1) of 4 residents reviewed.

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to prevent avoidable accidents by failing to ensure the appropriate storage of ignition devices for four (Residents #37, #67, #118 and #119) of 17 smokers observed with lighters in their rooms. The unsafe practice of allowing four of 17 residents who smoke to store unsecure ignition sources such as lighters in their rooms created a significant fire hazard from accidental ignition. A possible accidental ignition and fire risk created a likelihood of serious injury, impairment or death and resulted in the determination of Immediate Jeopardy.

Inspectors wroteBased on observation, record review, residents and staff interviews, the facility administration failed to provide effective oversight and failed to take appropriate actions to protect residents' safety from foreseeable and avoidable incidents from unsafe smoking practices and unsafe storage of ignition devices. This failure created an environment that placed four (Residents #37, #67, #118 and #119) of 17 resident smokers at a likelihood of serious injury, impairment or death from an accidental fire and resulted in the determination of Immediate Jeopardy.

Inspectors wroteBased on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's Resident Smoking Supervised and Unsupervised policy to ensure safe smoking practices for 4 (Residents #37, #67, #118 and #119) of 4 sampled residents reviewed for safe smoking out of 17 total smokers in the facility. The facility failure to enforce the smoking policy that clearly addressed the safe storage of ignition devices by allowing residents to keep lighters/ignition devices unsecured in their rooms created an avoidable fire safety risk, placing four of 17 resident smokers at a likelihood for serious harm, injury or death. These concerns resulted in the determination of immediate jeopardy.

Inspectors wroteBased on observations, interviews and record review, the facility failed to have sufficient staff to provide nursing care and services to maintain safety and the highest level of resident care needed to meet the needs of the residents, # 2, #12, #24 #50, #51, #52, #22, #25,#30, #133, and #140, by failing to ensure enough staff were available to respond to call lights and address resident concerns.

Inspectors wroteBased on observation and interview, 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 (Residents # 67, #16, #118, and #132) of 4 residents observed with medications left at bedside.

Inspectors wroteBased on interviews and record review the facility failed to respond and follow up with grievances and concerns brought forward by the resident council for 2 of 4 Resident Council meetings minutes reviewed (November and December 2025).

Inspectors wroteBased on record review, review of facility policy and procedure, residents and staff interviews, the facility failed to ensure prompt resolution and follow-up for grievances for 3 (Resident #12 Resident #2 and Resident #24) of 3 residents reviewed for grievances.

Inspectors wroteBased on interview and record review the facility failed to ensure Level 1 PASRR (Preadmission Screening and Resident Review Process- a federal requirement for nursing facilities to screen individuals for mental illness (MI), intellectual / developmental disabilities (ID/DD) to ensure appropriate placement and access to specialized services preventing unnecessary institutionalization and supporting community living) assessments were completed accurately and Level 2 pre-admission screening and resident review (PASRR) screenings were completed as required for 2 (Residents #8 and #50) of 3 residents reviewed.

Inspectors wroteBased on observation, record review, staff and resident review, the facility failed to provide the necessary services to maintain personal grooming and hygiene for 1 (Resident #132) of 3 residents requiring assistance with activities of daily living. This had the potential to cause psychological harm to the resident.

Inspectors wroteBased on clinical record review, residents and staff interviews, the facility failed to ensure 3 (Residents #7, #8, and #3) of 3 dependent residents reviewed received their scheduled showers.

Inspectors wroteBased on record review and interview, the facility failed to demonstrate prompt efforts to address grievances, including steps taken to investigate the grievance and failed to maintain evidence of the result of the grievance voiced by the family member of 1 (Resident #1) of 3 residents reviewed for grievances.

Inspectors wroteBased on observation, interviews, and records review, the facility failed to identify, investigate and prevent misappropriation of physician prescribed medication for 1 (Resident #4) of 3 residents reviewed.

Inspectors wroteBased on record review and staff interviews the facility failed to protect residents' right to be free from physical restraint for 1 (Resident #1) of 1 resident reviewed for restraints.

Inspectors wroteBased on observation, review of facility policy and procedure, review of the clinical record and resident and staff interview, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Resident # 899, #800 and #7) of 3 residents reviewed for ADL's (activities of daily living).

Inspectors wroteBased on observation, record review, staff and family interview, the facility failed to establish a communication process between the nursing facility, the hospice provider, and the responsible party to ensure the resident needs are met for 1 resident (#1) of 3 residents reviewed who are currently receiving hospice services. Hospice is a specialized form of medical care that provides comfort and quality of life while facing a life limiting or terminal condition. Coordination of care between facility services and Hospice services is vital to ensure the highest level of comfort and care during the end of life. The Findings Included: [...]

Inspectors wroteBased on records review, review of facility's policy and procedure, residents, and staff interviews, the facility failed to honor the bathing preferences for 4 (Residents #11, #15, #45 and #85) of 4 residents reviewed for bathing preferences.

Inspectors wroteBased on record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to file and maintain an accurate record of grievances for 3 (Residents #74, #83, and #3) of 3 residents reviewed. The findings Included: The facility Resident and Family Grievances policy Implemented 11/2020 and revised 3/8/2022 stated, It is the policy of this facility to support each resident's and family member's right to voice grievances . The policy noted the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form; Forward the grievance form to; the Grievance Official as soon as practicable; [...]

Inspectors wroteBased on record review, review of the facility's policies and procedures and staff interviews, the facility failed to ensure the appropriate Pre-admission Screening and Resident Review (PASARR) for 2 (Residents #87, and #77) of 2 residents admitted to the facility with a diagnosis of Serious Mental Illness or Intellectual Disability.

Inspectors wroteBased on observations, record review, review of facility's policies and procedures, and interviews, the facility failed to provide appropriate urinary catheter care and monitoring for 2 (Residents #64 and #85) of 2 sampled residents with urinary catheter to prevent urinary tract infections.

Inspectors wroteBased on review of the clinical record, review of facility policy and procedure and resident and staff interview, the facility failed to ensure freedom from significant medication error for 2(Resident #9 and #56) of 6 residents reviewed for medication administration. Failure to administer medications accurately puts residents at risk for adverse health consequences.

Inspectors wroteBased on observations, review of facility policy, staff and residents interviews, the facility failed to ensure safe storage of medications for 3 (Residents #3, #74, and #56) of 3 residents observed with unsecured medications at the bedside and 1 unlocked, unattended medication cart (South Unit) of 2 units observed.

Inspectors wroteBased on observation, review of facility policy and procedures, staff and resident interviews, the facility failed to protect the resident's right to privacy during medical treatment for 1(Resident #249) of 2 residents observed.

Inspectors wroteBased on observation and staff interview the facility failed to provide maintenance and housekeeping services to maintain a clean and homelike environment in 4 (Rooms 136, 138, 148, and 149) of 12 rooms observed on the South Unit.

Inspectors wroteBased on observation, review of the clinical record, review of facility policies and procedures, and resident and staff interviews the facility failed to provide the necessary care and services to maintain personal hygiene and bathing for 3 (Residents #1, #9 and #249) of 10 residents reviewed for activities of daily living.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure monitoring and care of cardiac pacemaker for 1 (Resident #90) of 1 resident reviewed for pacemakers.

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to provide an ordered therapeutic carbohydrate control diet for a diabetic for 1 (Resident #11) of 1 diabetic resident reviewed.

Inspectors wroteBased on observations, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to ensure that 1 (Resident #15) of 17 residents receiving respiratory treatment received physician ordered oxygen consistent with professional standards of practice, and the comprehensive person-centered care plan.

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to ensure process to support resident's rights to voice grievances for 5 (Residents #83, #31, #3, #12, and 41) of 5 residents reviewed.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to provide a written copy of the transfer notice to the resident and the Office of State Long Term Care Ombudsman (LTCO) office with written notice of hospital transfer and facility discharge for 3 (Resident #136, #137, and #139) of 4 sampled residents transferred to the hospital and discharged from the facility.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to provide the resident and their representative, if applicable, with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 9 (Residents #9, #24, #25, #30, #38, #66, #81, #82 and #285) of 10 residents reviewed for baseline care plans. This had the potential to cause confusion as to the care expected to be provided by the facility.

Inspectors wroteBased on observation, record review, resident and staff interview the facility failed to have documentation of an assessment to determine the ability to self-administer medications for 1 (Resident #43) of 1 resident observed with unsecured medication at the bedside.

Inspectors wroteBased on record reviews, staff and resident interviews and review of facility policies and procedures for Advance Directives, the facility failed to ensure proof of advance directives review and advanced care planning was in place for 2 (Resident # 285 and # 81) of 9 residents reviewed for Advanced Directives. This failure may impact quality of care at the end of life for the residents.

Inspectors wroteBased on record review, resident and staff interview, the facility failed to provide evidence a care plan conference was conducted with the resident and/or resident representative after completion of the comprehensive admission Minimum Data Set (MDS) assessment for 2 (Resident #82 and #25) of 2 residents reviewed. This did not allow the resident and/ or representative to participate in decision making related to the plan of care.

Inspectors wroteBased on observation, record review, staff and resident interview, the facility failed to ensure 2 (Residents #18 and #50) of 17 residents surveyed received activities according to the activities assessment, care plan, and the abilities of the resident. This has a potential to cause loneliness and mental anguish for residents.

Inspectors wroteBased on observation, record review, staff, and resident interviews the facility failed to assess, document, monitor, and provide care in a manner to promote healing for 1 (Residents #50) of 1 resident reviewed for edema (swelling caused by excess fluid). There was no evidence of a nursing assessment of the resident's edema to his lower legs to determine the extent of the swelling, blood flow to each leg, pain level, interventions which could be put in place to reduce the edema, and/or signs of infection. Ongoing monitoring and documentation of Resident #50's lower extremities allow clinical staff to detect complications and implement new interventions to prevent worsening of the lower extremity edema.

Inspectors wroteBased on observation, staff and resident interview, and review of facility policy and procedures, the facility failed to ensure the resident environment remains free of hazards and provide adequate supervision when smoking for 1 (Resident #17) of 2 resident reviewed for smoking.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to ensure proper storage and labeling of medications for 2 (Residents #43, and #385) of 7 sampled residents. The facility also failed to properly label and store medications in 2 (Medication Cart A and B ) of 2 medication carts observed on the North Unit.

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to maintain a safe, sanitary, and comfortable homelike living environment for 3 (Residents #48, #37, and #22) of 3 residents reviewed.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide 12 hours of annual in-service education for 2 (Staff L and Staff M) of 2 Certified Nursing Assistants reviewed.