Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure residents were transferred out of bed using
mechanical lift for 1 of 3 residents reviewed, Resident #4.
Residents Affected - Few
Findings include:
Review of Resident #4's admission record showed the resident was admitted on [DATE] with diagnoses
including type 2 diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, obesity,
depression, sleep apnea, muscle weakness, neuralgia and neuritis, Transient Ischemic Attack (TIA) and
cerebral infarction, and anemia.
Review of Resident #4's care plan showed the resident was at risk for decreased ability to perform ADLs
(Activities of Daily Living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer,
locomotion and toileting related to activity intolerance, CVA (Cerebrovascular Accident), recent
hospitalization, and recent illness.
During an interview on 8/21/2024 at 10:00 AM, Resident #4 stated, The Hoyer lift had dead batteries for 3
days, Friday [8/16/2024], Saturday [8/17/2024], and Sunday [8/18/2024]. They were not able to get me out
of bed.
During an interview on 8/21/2024 at 2:15 PM, Staff H, CNA, stated, Each unit has charging stations in the
clean utility room. We are having an issue with the batteries not charging.
During an interview on 8/21/2024 at 2:22 PM, Staff I, CNA, stated, We check the batteries prior to using
them. We are having an issue with the batteries.
During an interview on 8/22/2024 at 10:10 AM, Staff J, Certified Nursing Assistant (CNA), stated that
Resident #4 was assigned to her on Sunday (8/18/2024) and confirmed that she did not get the resident
out of bed. She stated, I went to 3 other units looking for batteries [for mechanical lift] that were charged,
and unable to find one.
During an interview on 8/22/2024 at 10:19 AM, Staff K, CNA, confirmed that she did not get Resident #4
out of bed on 8/17/2024, and stated, I had him on Saturday [8/17/2024]. He has other options to get out of
bed like the slide board, but he prefers to use the Hoyer. I went to another unit, the 500 Hall, but the
batteries had very low charge and did not work when put on the Hoyer.
During an interview on 8/22/2024 at 12:52 PM, with the Director of Nursing (DON) stated, Staff is expected
to go to another area to get a battery for the Hoyer lift if the ones in their area are not
(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 5
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
08/22/2024
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)
F 0558
functioning. I had not been informed that there was an issue.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105465
If continuation sheet
Page 2 of 5
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
08/22/2024
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)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation and interview, the facility failed to provide a clean and homelike environment
(Photographic evidence obtained).
Residents Affected - Few
Findings include:
During an observation on 8/21/2024 at 10:22 AM, there was a dead brown small pest in a cobweb noted
high on the left side of the bed directly below the ceiling tiles in Resident #5's room.
During an interview on 8/21/2024 at 10:22 AM, Resident #5 stated, I don't want bugs in my room.
During an observation on 8/21/2024 at 10:41 AM, the baseboard in Resident #1's room was peeling away
from the wall and there were multiple dead brown small pests inside the baseboard. There were three dead
brown small pests inside the cobwebs high on the walls. There were two dead brown small pests above the
windows and one on the left side of the bed below the ceiling tiles, all three in cobwebs.
During an interview on 8/21/2024 at 10:41 AM, Resident #1 stated, I see live bugs crawling all over
especially in the bathroom. If they sprayed in here, I don't remember. I don't know if those bugs are alive or
dead bugs on the walls, but they are gross. They should clean them off.
During an observation on 8/21/2024 at 10:44 AM with Staff A, Housekeeper, there was a dead small brown
pest in cobweb in the corner by the head of the bed in Resident #9's room.
During an interview on 8/21/2024 at 10:44 AM, Staff A, Housekeeper, acknowledged the dead small brown
pest in cobweb in the corner by the head of the bed in Resident #9's room.
During an observation of Resident #1's and Resident #5's rooms on 8/21/2024 at 2:54 PM, with the
Housekeeping Supervisor, he confirmed the dead bugs present in the cobwebs.
During an interview on 8/21/2024 at 2:54 PM, the Housekeeping Supervisor stated, The rooms need to be
cleaned and dusted. The floors and any touchable areas are to be cleaned every day. Cobwebs and bugs
should be dusted away every day. The staff will have to look up high. We were treating one hall at a time,
and I believe that plays a role in some of the rooms having bugs. I wonder if they are going into the ceilings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105465
If continuation sheet
Page 3 of 5
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
08/22/2024
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to ensure that residents received treatment and care
in accordance with professional standards of practice when a dietary supplement for wound healing was
not provided as ordered for 1 of 3 residents, Resident #2.
Residents Affected - Few
Findings include:
Record review of Resident #2's clinical record revealed resident was admitted with diagnosis that included
pressure ulcers, paraplegia, muscle wasting, and atrophy.
Review of Resident #2's physician orders dated 8/14/2024 read Juven [a supplement that provides
essential nutrients for wound healing] two times a day for supplement Juven 1 packet w/(with) 8 oz
(ounces) water BID (twice a day).
Review of Resident #2's Medication Administration Record (MAR) dated 8/1/2024 - 8/31/2024 revealed that
Juven was not documented as administered on 8/16, 8/17, 8/18 (2 doses), 8/21 (2 doses), and 8/22. There
was no documentation in the chart where the doctor or nutritionist was informed that Juven was not
available and was not administered.
During an interview on 8/21/2024 at 2:50 PM, Resident #2 stated, I'm really worried now about my wound. I
am not receiving the drink that I am supposed to get twice a day to help my wounds heal. I don't know the
name, its protein or something. They said [the facility] they didn't have any.
During an interview on 8/22/2024 at 2:25 PM, Staff O, LPN stated that she was assigned to [Resident #2's
Name] and he was not provided Juven because she did not have it on her cart, and she did not call and
notify the physician to inform him that the medication was not given.
During an interview on 8/22/2024 at 2:30 PM, Staff P, Dietician, stated, I was not told that Juven was not
available. If Juven or any nutritional supplement is ordered and not available, the physician and the
nutritionist needs to be contacted so, if necessary, a replacement can be ordered. I was not told that Juven
was not available.
During an interview on 8/22/2024 the Director of Nursing stated, I expect physician orders to be followed
and if the order cannot be followed the physician is to be notified.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105465
If continuation sheet
Page 4 of 5
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
08/22/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on interview and record review, the facility failed to ensure resident environment was free of accident
hazards by failing to ensure locks on the beds worked for 1 of 3 residents reviewed for accidents, Resident
#2.
Findings include:
During an interview on 8/31/2024 at 2:50 PM, Resident #2 stated, I tried to transfer to the bed from the
wheelchair, which I have done for years. The bed was not locked. The bed moved and I fell to the floor. The
bed would not lock. It was broke.
Review of Work Order #5582 for Resident #2's bed dated 8/1/2024 showed it read, Room/Area: [Resident
#2's room number] . Comments: bed wheels replaced 8/2/24.
Review of Work Order #5641 for Resident #2's bed dated 8/13/2024 showed it read, Notes: Resident stated
that the bed is not going down. It is causing resident to be unable to on his feet.
During an interview on 8/22/2024 at 12:51 PM, the Maintenance Director stated, The bed would not lock,
and an order was placed in TELLS [communication tool for maintenance work orders]. I do not have a
routine schedule to routinely check the beds to make sure the wheels lock or the beds are functioning
appropriately and are safe. When the residents or staff find a problem, the staff just place an order in
TELLS and I fix whatever needs to be fixed.
During an interview on 8/22/2024 at 3:10 PM, the Director of Nursing stated, [Resident #2's name] bed
would not lock. An order was placed. I'm not sure that maintenance has a routine maintenance check for
bed safety.
During an interview via telephone on 8/22/2024 at 3:49 PM, Staff C, Registered Nurse, stated, [Resident
#2's name] uses the bed and wheelchair to move by himself. Two days after he came from the hospital, I
heard him yelling out and I went in to help him. He fell trying to transfer from the wheelchair to the bed. The
bed was not working. It would not lock. Honestly, I do not check the beds to see if they lock. That's
maintenance or other attending staff. If someone checks the beds, I don't know who it is.
During an interview on 8/22/2024 at 4:00 PM, the Director of Nursing stated, It was identified that the bed
would not lock. No correction plan was initiated after discovery that the bed would not lock, and the resident
fell. No action plan was initiated to check the beds routinely to prevent in the future. No education was
provided to staff on bed checks for functionality.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105465
If continuation sheet
Page 5 of 5
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
FAQ · About this visit
Common questions about this visit
What happened during the August 22, 2024 survey of AVIATA AT ARBOR SPRINGS?
This was a inspection survey of AVIATA AT ARBOR SPRINGS on August 22, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVIATA AT ARBOR SPRINGS on August 22, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.