Avante At Ocala, Inc

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.

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