Health inspection·December 10, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on record review and interview the facility failed to notify the resident and the resident's representative of the transfer and the reasons for the move in writing in a language and manner they understand for 3 of 3 residents, Residents #1, #4, and #5, reviewed for discharge and/or transfer. Findings include: Review of Resident #1's clinical record contained a document titled SNF/NF [skilled nursing Facility/Nursing Facility] to hospital Transfer Form that read, Sent to [name of hospital] 11/13/2025 00:30 [12:30 AM]. Review of Resident #1's clinical record contained a document titled Nursing Home Transfer and Discharge Notice dated 11/13/2025 transferred to [name of hospital]. Review of Resident #1's clinical record did not contain documentation of the resident and the resident's representative being notified in writing of the transfer and the reason for the transfer. Review of Resident # 4's clinical record contained a document titled SNF/NF to hospital Transfer Form that read, Sent to [name of hospital]. Dated 11/11/2025 11:00 [AM]. Review of Resident #4's clinical record contained a document titled Nursing Home Transfer and Discharge Notice dated 11/11/2025 transferred to [name of hospital]. Review of Resident #4's clinical record did not contain documentation of the resident and the resident's representative being notified in writing of the transfer and the reason for the transfer. Review of Resident #5's clinical record contained a document titled SNF/NF to hospital Transfer Form that read, Sent to [name of hospital. Dated 11/14/2025 14:29 [2:29 PM]. Review of Resident #5's clinical record contained a document titled Nursing Home Transfer and Discharge Notice dated 11/14/2025 transferred to [name of hospital]. Review of Resident #5's clinical record did not contain documentation of the resident and the resident's representative being notified in writing of the transfer and the reason for the transfer. During an interview on 12/10/2025 at 1:55 PM Staff D, LPN [Licensed Practical Nurse] Unit Manager stated, All the transfer documents are put in a packet and given to EMS [Emergency Medical Services]. Nothing is given in writing to the residents, just a verbal on why they are being sent out. During an interview on 12/10/2025 at 3:24 PM E, LPN stated, We do a change in condition and transfer out to the hospital. We complete it with a transfer form. We call the ER [Emergency Room] on why we are sending the patient. We provide a transfer summary, face sheet, orders to EMS so that they have medication and orders. Nothing is given to the patient, we tell them exactly why they are going out, who ordered for the transfer and where they are going. We try to ask if they have a preferred hospital. During an interview on 12/10/2025 at 3:35 PM Staff C, LPN stated, I would talk to the resident to see if they wanted to go to the hospital. We do not hold them. I will let them go and send them to the hospital. I would send the face sheet, medication list and DNR [Do Not Resuscitate] yellow form. I would give the transfer forms to EMS, complete a change of condition in the computer, and the resident gets the bed hold that they sign everything else goes to EMS. I tell them [the resident] who is sending them and why they are going and what hospital they are going to. During an interview on 12/10/2025 at 4:23 PM Staff B, LPN stated, The transfer papers are given to EMS, all the paperwork, which includes the transfer Page 1 of 3 105465 105465 12/10/2025 Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some summary, face sheet, doctor orders and medications. I never give the paper to the residents at the time of transfer it's always given to EMS. During an interview on 12/10/2025 at 4:27 PM the Director of Nursing stated, We have always completed a transfer summary, change of condition, and provided EMS with the transfer summary, face sheet, physician orders and tell the resident why they are going out and who sent them to the hospital. We cannot tell them the exact hospital because we do not know where they are going because EMS determines based on availability. We do not hand the papers for transfer to the resident because it would get lost. EMS gives the papers to the hospital. We do not give anything to the residents. Review of the policy and procedure titled Discharge and Transfer with an effective date of 11/30/2014 read, The Company will ensure that transfer or discharge is safe, orderly and is appropriate to meet the needs of the resident. 105465 Page 2 of 3 105465 12/10/2025 Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staff followed infection control standards for transmission-based precautions to prevent the possible spread of infection and communicable diseases for 1 of 3 residents reviewed for infection prevention and control practices, Resident #2.Findings include: Review of the clinical record for Resident #2 documented the resident was admitted into the facility on [DATE] with a diagnosis of pseudomonas aeruginosa (a bacteria that is considered to be a multi-drug-resistant organism) a urinary tract infection (UTI). Review of Resident #2's physician orders dated 12/10/2025 read Contact isolation for pseudomonas aeruginosa in urine (UTI). Review of the Isolation precaution signage posted on the PPE (personal protective equipment) rack read Stop - Contact precautions everyone must: clean their hands, including before entering and when leaving the room, with soap and water. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. During an observation on 12/10/2025 at 09:30 AM Staff A, Certified Nursing Assistant (CNA) entered Resident #2's room without wearing PPE, (gown/gloves). The Resident's room had (PPE) stored and readily available in a rack hanging on the door from outside. The isolation precaution signage was posted on the rack. (Photograph evidence obtained). Staff A, CNA entered the room with no PPE donned and proceeded to move Resident #2's personal belongings around on top of the bedside table. Staff A, CNA then left the room. During an interview on 12/10/2025 at 09:3 5AM Staff A, CNA stated, I wound only put on the gown, gloves, or a mask if I was doing something for the patient. I don't have to wear gown or anything if I am not touching the resident. During an interview on 12/10/2025 at 09:39 AM Staff B, License Practical Nurse (LPN) Supervisor stated, [Resident #2's room number] is on contact isolation and the staff should be coming and asking if they do not understand what they should be wearing. Anyone entering a contact isolation room should wear a gown, mask and gloves. During an interview on 12/10/2025 AT 4:27 PM the Director of Nursing stated, [Resident #2's name] is on contact precautions and staff should be finding out what type of PPE is required by asking the nurse, if they do not know what to wear. With contact precautions I expect the staff to wear a gown, gloves and mask when entering the room. Review of the policy and procedure titled Isolation - Categories of Transmission - Based Precautions read, Contact precautions 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with a resident or indirect contact with environmental surfaces or resident care items in the residence environment. 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While caring for a resident staff will change gloves after having contact with infective materials, for example fecal material and wound drainage. B. Gloves will be removed and hand hygiene performed before leaving the room. C. Staff will avoid touching potentially contaminated environmental surfaces or items in the residence room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Residents Affected - Few 105465 Page 3 of 3