Health inspection·December 19, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure adequate supervision during toileting to prevent an accident resulting in head injury and transferred to a higher level of care for 1 of 3 residents reviewed for accident prevention (Resident #1). Findings include: Review of Resident #1's admission record documented diagnosis to include wedge compression fracture of first and fifth lumbar vertebra, Huntington's Disease, and ataxia (poor muscle control that affects balance and coordination). Review of the fall risk assessment for Resident #1 dated 12/14/2024, revealed a score of 13. A Score 10 or higher indicated the resident is at high risk of falls. Review of Resident #1's progress note dated 12/18/2024 documented, Late entry. Staff A, CNA [Certified Nursing Assistant] reports toileting resident and allowed her privacy and upon return to bathroom resident on left side appearing to bleeding {sic} from head. Resident states 'I fell.' Review of Resident #1's progress note dated 12/19/2024 documented, Resident returned from ER visit, skin assessment was completed. Resident with skin tear/abrasion to her left lateral leg .bruising to her left eye and a small, raised area to the left lateral forehead. There was a raised area/protrusion to the right shoulder with bruising to the area. Review of Resident #1's care plan, date initiated 10/19/2024 and revised 12/19/2024, documented Resident at risk for falls related to general weakness, impaired mobility, ataxia, Huntington's Disease, 1st lumbar vertebra fracture, 5th lumbar vertebra fracture, failure to thrive, poor safety awareness, impulsiveness, incontinent of bowel and bladder and opioid/psychotropic medication use. Resident #1's care plan documented fall precaution interventions that included Guest is not to be in bathroom without staff present. Date added to care plan: 12/16/2024. During interview on 12/18/2024 at 2:02 PM, the Director of Nursing stated Staff A, CNA found the resident [Resident #1] bleeding on the bathroom floor has been suspended. He had been suspended pending investigation because he had not followed Resident #1's care plan related to supervision in the bathroom. The certified nursing assistant should have known to check the [NAME] [a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan] for any care plan intervention updates. The Director of Nursing added the resident's [Resident #1] care plan had been updated to include not leaving her alone in the bathroom (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: 105562 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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)