Health inspection·October 14, 2025

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 implement care plan interventions related to management of a metabolic condition/concern related to hypokalemia for 1 (Resident #4) of 3 residents reviewed for nutritional services and failed develop a care plan to address 1 (Resident #1) of 3 with a diagnosis of post traumatic stress disorder reviewed for behavioral health.Findings include: 1.) Review of Resident #4's care plan, initiated 8/16/2023, documented Resident #4 had a metabolic condition/concern related to hypokalemia [low potassium]. Resident #4's care plan documented nutritional interventions that included, RD [Registered Dietician] to evaluate quarterly and PRN [as needed]. Monitor caloric intake, observe/review/estimate needs and make recommendations as indicated. Review of Resident #4's clinical record failed to reveal documentation the Registered Dietician had completed quarterly evaluations of Resident #4 to monitor Resident #4's caloric intake and to observe/review/estimate Resident #4's needs or make nutritional recommendations as indicated. During an interview on 10/14/2025 beginning at 12:54 PM, the Director of Nursing confirmed Resident #4's care plan documented Resident #4 had a metabolic condition/concern related to hypokalemia and the care plan documented nutritional interventions that included RD to evaluate quarterly and PRN. Monitor caloric intake, observe/review/estimate needs and make recommendations as indicated. The Director of Nursing confirmed Resident #4 had not been evaluated by the RD quarterly to monitor Resident #4's caloric intake and to observe/review/estimate Resident #4's needs or make nutritional recommendations as indicated. The Director of Nursing added that the RD reviewed residents for weight loss quarterly and the RD would complete evaluations of those residents that had triggered for weight loss. Review of email correspondence dated 10/14/2025, to the facility Administrator from the Registered Dietician revealed Resident #4 had not triggered for a consultation with the Registered Dietician. The email correspondence documented Resident #4 had only been seen by the Certified Dietary Manager to update food preferences in May and August. 2.) Review of Resident #1's admission record documented an admission date of 06/16/2017 with diagnosis including but not limited to unspecified mood [affective] disorder, major depressive disorder, and post-traumatic stress disorder [onset date 7/31/2025]. Review of Resident #1's psychiatry subsequent note dated 8/12/2025, read, Chief complaint: Depression, anxiety, dementia, psychosis, insomnia, opioid abuse and PTSD [Post Traumatic Stress Disorder]. Reason for Today's encounter: Today I saw patient to assess tolerability and effectiveness after Page 1 of 2 106084 106084 10/14/2025 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few recent medication changes. History of Present Illness: This is an [AGE] years old patient with past psychiatric history of depression, anxiety, dementia, psychosis, insomnia, opioid abuse and PTSD. Prior to last visit, patient showed signs of psychosis. Nurse reported a patient's belief that he was in Vietnam. The patient acted as if he had a gun, seeing and ''shooting people.Rationale behind diagnosis: PTSD (Post Traumatic Stress Disorder) : The history suggest that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms lasted for month than one month and have occurred without any Substance use or organic brain pathology. Review of Resident #1's psychology subsequent note dated 10/10/2025, read, Chief Complaint: PTSD. History of Present Illness: Patient readily reports active PTSD.Patient is experiencing significant frequent flashbacks and nightmares related to serving for 32 years as a combat medic, and being held as a Prisoner of War in Vietnam. The symptoms occur almost daily and cause severe distress. Review of Resident #1's comprehensive care plan did not document a focus of Post Traumatic Stress Disorder. During an interview on 10/14/2025 at approximately 2:00 PM, the Director of Nursing stated, Most definitely [Resident #1's name] care plan should include a focus for PTSD and behaviors. During an interview on 10/14/2025 at 2:25 PM, the Minimum Data Set Coordinator stated, [Resident #1's name] care plan was reviewed, and I could not find PTSD as a focus. It will need to be included. Review of the facility policy and procedure titled Comprehensive Care Plan with an issued date of 4/16/2025, read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 11. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initial and when changes are made. 106084 Page 2 of 2