Inspection·May 1, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to keep an accurate record of resident treatments for 4 of 5 reviewed residents, Residents #2, #3, #4, and #5. Residents Affected - Some Findings include: Review of the physician's order for Resident #2 dated 4/5/2023 read, Left buttock: Clean w [with] N/S [Normal Saline], pat dry w gauze, apply medihoney, top w Ca [Calcium] alginate sheet, cover w bordered foam dressing daily. every day shift for wound care. Review of the Treatment Administration Record (TAR) for Resident #2 documented no wound care for the left buttock on 4/21/2023 and 4/28/2023. Review of the physician's order for Resident #3 dated 3/22/2023 read, Coccyx: Cleanse w N/S, pat dry w gauze, apply medihoney and collagen particle mixture, top w Ca alginate sheet, cover w bordered foam dressing. every day shift for Wound care. Review of the physician's order for Resident #3 dated 4/14/2023 read, Lt. [Left] lateral ankle: Clean w N/S, pat dry w gauze, apply medihoney, sprinkle with collagen particles, top w Ca alginate sheet, cover w bordered foam dressing. every day shift for Wound care . Rt. [Right] lateral ankle: Clean w N/S, pat dry w gauze, apply medihoney, sprinkle w collagen particles, top w Ca alginate sheet, cover w bordered foam dressing. every day shift for Wound care. Review of the TAR for Resident #3 documented no wound care for the coccyx on 4/4/2023, 4/21/2203, and 4/25/2023, no wound care for the left and the right lateral ankles on 4/21/2023 or 4/25/23. Review of the physician's order for Resident #4 dated 4/25/2023 read, Coccyx: Clean w N/S, pat dry w gauze, apply medihoney, pack wound w Ca alginate, top w bordered foam dressing daily. every day shift for Wound care. Review of the TAR for Resident #4 documented no wound care for the coccyx on 4/28/2023. Review of the physician's order for Resident #5 dated 4/10/2023 read Coccyx: Clean w N/S, pat dry w gauze, apply medihoney, Ca alginate, bordered foam dressing daily. Every evening shift for wound care. Review of the TAR for Resident #5 documented no wound care for the coccyx on 4/19/2023 and 4/25/2023. (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 2 Event ID: 105465 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 105465 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471 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)