Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0563
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Level of Harm - Minimal harm
or potential for actual harm
On 2/15/23 8:42 a.m., Resident #28 said the limited visitor hours bother him because his son comes to see
him and then in an hour he is told he has to leave. He said his son works and he just cannot visit anytime
during the day. Resident #28 said his son has a family and obligations that limit the time he can visit and if
the hours were longer he could see him more.
Residents Affected - Few
On 2/15/23 at 1:33 p.m., during a telephone interview Resident #28's son said the limited weekend
visitation hours are a problem. He said there is an announcement and visitors have to leave at 3:45 p.m. He
said he thinks the weekend hours should be longer and does not understand the limit.
Based on observation, facility policies and procedures, staff, resident, and family member interviews, the
facility failed to ensure residents' right to receive visitors at the time of their choosing for 3 (Resident #239,
#236, and #28) of 5 sampled residents.
The findings included:
Facility policy titled Right to Access and Visitation dated 10/3/2022, stated: Resident's family members are
not subject to visiting hour limitations or other restrictions not imposed by the resident, with the exception of
reasonable clinical and safety restrictions, placed by the facility based on recommendations of CMS
(Center for Medicare and Medicaid Services), CDC (Center for Disease Control), or the local health
department. And the facility will ensure all visitors enjoy full and equal visitation privileges consistent with
resident preferences.
The facility admission packet document titled skilled nursing facility rights stated, you have the right to
spend private time with visitors at any reasonable hour. The skilled nursing facility must permit your facility
to visit at any time as long as you want to see them.
On 2/13/23, 2/14/23, and 2/15/23 at 9:00 a.m., a sign was observed posted on the facility's entrance door
stating, Visitation hours Monday-Friday 8:30 a.m.- 7:45 p.m. and Saturday and Sunday 8:30 a.m.-3:45 p.m.
On 2/16/23 at 10:15 a.m., a sign read, Visitation hours Monday-Friday 8:30 a.m.- 7:45 p.m. and Saturday
and Sunday 8:30 a.m.-3:45 p.m. The above hours are when reception is on duty to properly check you in
according to COVID protocols. The door is locked at other times.
Please inform us if you desire any exceptions to these hours .
Inside the front doors at the front reception desk, a sign was posted that stated, Visiting hours
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
106129
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106129
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Terracina Health & Rehabilitation
6869 Davis Boulevard
Naples, FL 34104
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0563
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
were Monday-Friday 8:30 a.m.-7:45 p.m. and Saturday and Sunday 8:30 a.m.-3:45 p.m. The sign also noted
the front doors will remain locked when visiting hours are over. No visitors will be allowed in the building
except during the posted schedule. No Exceptions!
On 2/13/23 3:47 p.m., resident #239 stated he was surprised by having limited visitation hours yesterday.
He stated his friend told him there was a card that said visitation ended at 3:45 p.m., which was pretty early.
Maybe they don't enforce them. I just thought that was early.
On 2/15/23 1:41 p.m., resident #236 stated he would like his caregiver to have additional visitation time.
They both live out of town, and visiting hours end at 4:00 p.m., because the receptionist leaves and the
doors are locked. Both stated they would prefer the flexibility to have visitation later in the day on the
weekends.
On 2/14/23 at 4:26 p.m., Licensed Practical Nurse (LPN) Staff nurse A stated if the resident has family that
wants to spend the night, they are allowed since everyone is in a private room.
On 2/15/23 at 8:41 a.m., the receptionist pointed to the sign at the desk with the visitation hours and
showed hours end at 3:45 p.m., on weekends. She stated if someone wants to stay past the posted hours,
they need to let the staff know in advance since the receptionist leaves at 4:00 p.m.
On 2/15/23 at 9:05 a.m., LPN Staff C stated visitation ends at 7:45 p.m., during the week and 3:45 p.m. on
weekends. When visitation is about to end, an overhead announcement is made that the door will be locked
so families know to head out.
On 2/15/23 at 2:37 p.m., The Social Service Director (SSD) stated visitation hours were posted. The main
reason for nighttime is because the doors automatically lock, so they have to push the call bell to ring. On
the weekend it's a shorter time visit. We do have flexibility if someone asks, we do allow them. I have only
been asked once or twice. I have never seen staff ask anyone to leave. We allow visitors to spend the night
if the administration approves it in advance. The room isn't ideal for long-term visitation.
On 2/15/23 at 5:04 p.m., the administrator stated visitation is from 8:30 a.m. to 7:45 p.m., and ends at 3:45
p.m., on weekends. Visitors can still come buzz and come in anytime. We tell people that all the time. We
had extended hours on Superbowl Sunday and New Year's Eve.
On 2/16/23 at 12:16 p.m., the activity director confirmed, visitation ends at 3:45 p.m., but on Superbowl
Sunday, some of the spouses wanted to stay late, so we gave them permission to stay.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106129
If continuation sheet
Page 2 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106129
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Terracina Health & Rehabilitation
6869 Davis Boulevard
Naples, FL 34104
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, record review and policy review the facility failed to address a significant change
in weight in a timely manner for 1 (Resident #182) of 3 residents reviewed for weights.
Residents Affected - Few
The findings included:
Review of facility policy titled, Weight Monitoring Policy, reviewed 10/24/2022 which stated:
Policy: Based on the resident's comprehensive assessment, the facility will ensure the resident maintains
acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition
demonstrates that this is not possible.
Policy Explanation and Compliance Guidelines:
2. The newly recorded resident weight should be compared to the previous recorded weight. A significant
change in weight is defined as: (a) 5% change in weight in 1 month (30 days); (b) 10% change in weight in
6 months (180 days)
3. Documentation (a) The physician should be informed of a significant change in weight and may order
nutritional interventions.
Review of facility policy titled Notification of Change Policy reviewed 10/25/2022 which stated:
Policy: The facility will inform the resident; consult with the resident's physician; and if known, notify the
resident's legal representative or appropriate family member(s) of the following: . 2. A significant change in
the physical, mental, or psychosocial status of the resident.
Policy Explanation and Compliance Guidelines:
1. In the case of a competent resident, the facility will contact the resident's physician and appropriate
family members . 5. Document in the resident's clinical record the date and time of the notification.
On 2/13/2023 at 10:20 a.m., Resident #182 was observed with bilateral foot and ankle edema (swelling),
and intermittent cough.
Resident #182 daughter was present in the room and said, I did not realize how swollen her feet were until
today. We tried to put her shoes on, and they did not fit.
On 2/14/2023 at 11:00 a.m., clinical record reviewed for Resident #182. Resident was admitted to the
facility on [DATE] for rehabilitation after a right hip fracture. Diagnoses listed included heart failure.
Resident #182 had an admission weight completed on 2/2/2023 documenting weight 114.0 pounds.
On 2/10/2023 the resident's weight was documented at 124.6 pounds.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106129
If continuation sheet
Page 3 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106129
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Terracina Health & Rehabilitation
6869 Davis Boulevard
Naples, FL 34104
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
This weight change of 10.6 pounds showed a significant weight gain of 9.3% over an eight day period.
Level of Harm - Minimal harm
or potential for actual harm
No documentation was found in the clinical records, including progress notes, assessment notes and
change in condition notes reviewed to show the physician was informed of the significant weight change.
There was no documentation of additional interventions implemented to manage the significant weight
increase.
Residents Affected - Few
The Comprehensive care plan initiated on 2/6/2023 did not address the risk for edema for resident.
On 2/13/23 documentation in the clinical record noted Resident #182 developed a cough on 2/12/2023 and
edema to both lower extremities on 2/13/2023.
On 2/15/23 at 9:06 a.m., Certified Nursing Assistant (CNA) Staff G said residents are weighed on
admission and then are weighed weekly unless they have an order for daily weights. CNA Staff G said the
nurses check the weights to see if there is a concern.
On 2/15/23 at 9:28 a.m., Registered Nurse (RN) Staff F said the residents are weighed on admission and
then weekly unless ordered due to a medical diagnosis such as congestive heart failure patients might
have daily weights. If there is a weight change of three or more pounds they contact the physician and
document the notification in the progress notes. RN Staff F reviewed Resident #182 weight history and
confirmed the significant weight gain. RN Staff F said, It absolutely should have been addressed earlier. I
don't know why it wasn't.
On 2/15/23 at 9:43 a.m., the Director of Nursing (DON) said if there is a significant weight change, the
nurse is expected to notify the physician and document the notification.
The DON reviewed Resident #182's clinical record and confirmed there was no documentation the nurse
notified the physician for the 9.3% weight gain on 2/10/2023. The DON said the expectation is that they
would have been notified and it would have been documented. The DON confirmed the resident developed
cough and edema after the significant weight gain and required a chest X-ray and Lasix medication which
were both ordered on 2/13/2023.
On 2/16/23 at 9:16 a.m., the Registered Dietician (RD) said she saw the significant weight gain during her
routine weights review. She had not received any communication regarding the weight gain.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106129
If continuation sheet
Page 4 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106129
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Terracina Health & Rehabilitation
6869 Davis Boulevard
Naples, FL 34104
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to provide care and services to prevent the
development of pressure ulcers in 1 (Resident #28) of 1 resident with an in-house acquired pressure ulcer.
Residents Affected - Few
The findings included:
Review of Resident #28's Hospital Transfer Form (Agency for Health Care Administration (AHCA) Form
5000-3008) dated 1/11/23 revealed Resident #28 had an incision and drainage of a right foot infection and
wore a surgical boot. Resident #28 did not have any pressure ulcers listed on the transfer form.
Review of the Hospital Physical Therapy Treatment Record History of Present illness dated 1/9/23 revealed
Resident #28 had surgery to the right foot on 12/30/22 and instructions for surgical shoe at all times.
Physical Therapy goals included surgical shoe at all times for ambulation, bed mobility, and transfers
starting 1/3/23 and ending 1/17/23.
Review of the clinical record revealed Resident #28 had an admission date of 1/11/23.
The admission Minimum Data Set (MDS) assessment with an assessment reference date of 1/17/23 noted
Resident #28's cognition was intact. Resident #28 did not have any behaviors. The assessment noted the
resident had a surgical wound but no unhealed pressure ulcer. Resident #28 required extensive assistance
of two staff members for dressing.
Review of the Occupational Therapy (OT) Notes for Resident #28 from 1/12/23 - 2/3/23 revealed
documentation lists surgical shoe on right foot for ambulation. under precautions.
Review of the OT Notes for Resident #28 signed 2/16/23 revealed precautions, Do not use surgical shoe
when ambulating per physician order dated 2/3/23.
Review of the facility physician's orders, Medication Administration Records (MARS), Treatment
Administration Records (TARS), Care Plans and progress notes revealed no nursing directions or
interventions for Resident #28's surgical shoe.
Review of the Nursing Skin/Wound Progress Note dated 1/31/23 at 7:23 p.m., revealed Resident #28 had
an unstageable pressure ulcer to the right Achilles.
Review of the Wound Physician's Initial Wound Evaluation dated 2/2/23, Resident #28 has an unstageable
wound (due to a device/dressing) of the right upper heel for at least 14 days duration.
On 2/13/23 at 4:02 p.m., Resident #28 said he had a bandage on the back of his heel. He said he wore a
black surgical boot when he was admitted to the facility.
On 2/14/23 at 3:47 p.m., Certified Nursing Assistant (CNA) Staff H said Resident #28 has a wound on the
right heel. Staff H said Resident #28 wore the surgical shoe when he was admitted to the facility.
On 2/15/23 at 11:12 a.m., the Director of Nursing confirmed Resident #28's unstageable pressure
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106129
If continuation sheet
Page 5 of 6
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106129
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens at Terracina Health & Rehabilitation
6869 Davis Boulevard
Naples, FL 34104
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
ulcer was acquired at the facility.
Level of Harm - Minimal harm
or potential for actual harm
On 2/15/23 at 2:20 p.m., the Wound Care Physician who saw Resident #28 initially on 2/2/23, confirmed
Resident #28 had an unstageable pressure ulcer that was caused by the surgical shoe.
Residents Affected - Few
On 2/15/23 at 2:38 p.m., Resident #28 said he wore the surgical shoe for about three weeks. Resident #28
stated, If the facility told him to do something he did it, and if they told him not to do it, he stopped. Why
would I want to wear that surgical shoe if I didn't need to? A surgical shoe was observed in the resident's
room.
On 2/15/23 at 6:36 p.m., the Minimum Data Set (MDS) Coordinator said there was no nursing
documentation indicating how long Resident #28 was wearing the surgical shoe. The MDS Coordinator said
the surgical shoe was not in the physician's orders, the Medication Administration Records (MARS), the
Treatment Administration Records (TARS) or the care plans for Resident #28.
On 2/16/23 at 9:30 a.m., CNA Staff I said she takes care of Resident #28, and he wore the surgical shoe
when he was admitted . She said Resident #28 showers every day. She assisted Resident #28 with
dressing, including putting on the surgical shoe.
On 2/16/23 at 10:21 a.m., the Director of Nursing confirmed there was no physician's order for Resident
#28 to wear the surgical shoe. She said there should have been an order with time frames and when to
stop wearing it, but there were not. She said there were no directions for the surgical shoe in the care plan
or the CNA [NAME] (contains resident's care information) .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106129
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F563 - The resident has a right to receive visitors of his or her choosing at the time o
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the February 16, 2023 survey of GARDENS AT TERRACINA HEALTH & REHABILITATION?
This was a inspection survey of GARDENS AT TERRACINA HEALTH & REHABILITATION on February 16, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDENS AT TERRACINA HEALTH & REHABILITATION on February 16, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.