Health inspection·June 12, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that meets the medical, nursing, and mental and psychosocial needs for 1 of 3 residents. (Resident #2) Findings include: Review of the admission record documented Resident #2's admission diagnoses included cardiomyopathy, type 2 diabetes mellitus without complications, presence of automatic implantable cardiac defibrillator, chronic viral hepatitis, alcoholic hepatitis without ascites, idiopathic peripheral autonomic neuropathy, hypothyroidism, paroxysmal atrial fibrillation, major depressive disorder, primary insomnia, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic obstructive pulmonary disease (COPD). Review of the nursing progress note for Resident #2 dated 4/14/23 at 7:34 AM reads, Resident came out of room, leaned on wall, got dizzy, fell on bottom and then hit head. Resident has a small laceration and hematoma to left side of forehead. He also has a bruise on his left side of arm. Vitals were taken notified APRN (Advanced Practice Registered Nurse) [APRN name], called emergency contact, notified ADON (Assistant Director of Nursing) resident refused to go to hospital after falling. Resident even refused in front of EMS (Emergency Medical Services). After the resident thought about it he finally went with EMS to the hospital. His breath smells like alcohol. A cup was found in his room that smells like alcohol is in it. He is alert but has some slurred speech . Review of the hospital documentation for Resident #2 present in the medical record dated 4/16/23 reads, Date of admission 4/16/2023, History of present illness: Patient is a [AGE] year-old Caucasian male who presented to the emergency department with reports of syncope. He was brought via EMS from [facility name], as he had an acute unwitnessed fall today, and was found on the floor in his room with an unknown downtime and unknown if he had any loss of consciousness, yet it is known that he struck his head as he presented to the ER (emergency room) with a laceration to his left eyebrow with active bleeding. Patient endorses during my time of interview/examination with him, that he was drinking vodka today in his room. Patient endorses current tobacco use. Onset age [AGE]. Further endorses alcohol use. He is vague with answering how much alcohol he drinks and endorses that he does typically drink on a daily basis, and that his alcohol of choice is vodka. He states he averages 1.75 L (liters) of vodka every few days. Endorses that he is at a skilled nursing facility [Facility name] and has the alcohol delivered with his groceries. emergency room work up ., Ethanol level 251 (ref range 0-10 mg/dl [milligrams per deciliter]). Assessment/Plan: unwitnessed syncope prior to hospitalization, laceration left eyebrow, initial encounter, ETOH (alcohol) intoxication, essential hypertension, paroxysmal atrial fibrillation, coronary artery disease, cardiomyopathy, COPD with exacerbation (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 06/12/2023 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)