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 (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 3 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 12/10/2025 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)