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 interview and record review the facility failed to ensure residents medical records were complete
and accurate for 1 of 3 residents, Resident #1, reviewed for mood and behaviors.
Residents Affected - Few
Findings include:
Review of the Active Orders for Resident #1, physician's order dated 12/25/2024, provided for a
documentation system to track Resident #1 for behavior monitoring and staff interventions that read as
follows, Behavior code-0-no behavior, 1-Fear/panic, 2-anger, 3-Scream/yell, 4-Danger/self/others,
5-Delusions, 6-Hallucinations, 7-Sad/tearful, 8-Emotion/Acts withdrawal, 9-other. Interventions 1-music/aromatherapy, 2-Reminiscence/reality orient, 3-Exercise/activity, 4-1:4 5-Reduce stim [stimuli]
6-PRN [as needed] med outcome I-improved S-Same, W-Worse, Side Effects - 0-none, 1-EPS
[extrapyramidal symptoms] 2-Tardive Dys [Dyskinesia] 3-Hypotension, 4-Inc behavior, 5-Sedation/drowsy,
6-Inc Falls/dizzy as needed for behavior.
Review of Resident #1 physician order dated 3/16/2025 read, Depakote Sprinkles Oral Capsule Delayed
Release Sprinkle 125 MG (milligram)give 250 mg by mouth two times a day related to dementia in other
disease classified elsewhere unspecified severity with mood disturbance.
Review of Resident #1's physician order dated 3/16/2025 read, Trazadone HCI Oral Tablet 50 mg
[milligrams] give 1 tablet by mouth three times a day related to depression.
Review of Resident #1 Treatment Administration Record for the month of April 2025 documented only
check marks and staff initials for Behavior monitoring.
During an interview on 4/30/2025 at 11:45 AM Staff A, License Practical Nurse (LPN) stated, We should
document whether a resident is or is not having behaviors in our treatment record.
Review of Resident #1's progress note dated 4/25/2025 written by Advance Registered Nurse Practitioner
(APRN #1) read, Chief Complaint: Behaviors. History of present illness: Reports patient was blocking the
door on 4/24/2025. Patient is in no acute distress at this time. Staff reports he is taking all medications as
prescribed, tolerating well
Review of Resident #1's progress note on 4/24/2025 read, Resident is stable. Still refusing to take his
meds. Providers are aware. No behaviors noted throughout this shift.
During an interview on 4/30/2025 at 11:54 AM ARNP #1 stated, The staff did tell me he [Resident #1] was
refusing all his medications.
(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:
106084
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
106084
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avante at Ocala, Inc
2021 SW 1st Ave
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 4/30/2025 at 12:57 PM the Director of Nursing stated, Behavior documentation in
the treatment record and the supplementation option was not added. It should have had the option for a
number to be coded which would provide details of the behaviors if any. The ARNP [ARNP #1] stated she
dictates her notes and it should have said [Resident #1's name] does not take his medications. Staff and
providers should document accurately.
Residents Affected - Few
Review of the facility policy and procedure titled Documentation with a last reviewed date of 1/25/2025
read, Policy: Each Resident's medical record shall contain an accurate representation of the actual
experiences of the resident and include enough information to provide a picture of the resident's progress
through complete, accurate, and timely documentation.
Review of the facility policy and procedure titled Behavior and Psychoactive Management Program with a
last reviewed date of 3/2/2019 read, Procedure: 3. Monitoring the resident's behavior(s) to establish
patterns, determine intensity and behavior frequency, and identifying the specific (targeted) behaviors that
are distressing to the resident which are decreasing resident's quality of life.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106084
If continuation sheet
Page 2 of 2
