Aviata at Big Bend: Communication Aid Denied - FL
Resident #11 told inspectors on September 8 that he has trouble communicating. His roommate said he had asked staff several times to get a communication board for the resident, but they never provided one. The resident confirmed he had never received the board and explained it would help him let staff know what he needs.
No communication board was found in his room.
The resident's care plan, last reviewed in June, contained a contradiction that revealed the facility's failure. One section stated that "Resident #11 has a communication board but can communicate without it if given time." Another section listed communication problems related to aphasia as a focus area requiring intervention.
The care plan specified that staff should evaluate the resident for his ability to use a communication board, writing, computer, or sign language as alternatives to speech. It also required a referral to speech therapy for evaluation and treatment.
That referral was supposed to happen on January 21, 2022.
More than three years later, it still hadn't been made.
Inspectors found no orders for speech therapy, occupational therapy, physical therapy, or evaluation in the resident's medical records since his admission. When the MDS Coordinator was asked for evidence of the speech therapy referral documented in the care plan, she couldn't find it.
She called the facility's contracted speech therapy director, who also couldn't locate any referral or visit notes for the resident.
Asked whether the referral or communication board had been followed up on, the MDS Coordinator admitted "it doesn't look like it was."
The resident's care plan outlined extensive goals for maintaining his involvement in cognitive stimulation and social activities. Staff were supposed to converse with him while providing care, arrange community activities, and ensure activities matched his physical and mental capabilities. The plan called for adapting activities with large print or holders if the resident lacked hand strength, and providing bedside visits if he couldn't attend out-of-room events.
But without the basic communication tool he needed, the resident remained unable to effectively tell staff what he wanted or needed.
The facility's failure extended beyond one resident. Inspectors documented another incident involving Resident #4, who became combative and agitated during "continued attempts to leave the facility." Staff lost control of the situation and called law enforcement. Police arrived after the resident had been redirected back inside, but the resident "continues to be combative and agitated," according to the inspection report.
The communication board case represents a particularly stark example of neglect because the solution was simple and the need was clearly documented. The resident had been living with untreated communication difficulties while his care plan falsely claimed he already had the tool he needed.
His roommate's repeated requests to staff went ignored. The required speech therapy referral sat incomplete for over three years. The resident continued to struggle with basic communication about his daily needs.
Federal inspectors cited the facility for actual harm to residents, finding that some residents were affected by the facility's failure to provide appropriate treatment and services. The communication board violation fell under regulations requiring nursing homes to provide necessary care and services to help residents attain or maintain their highest practicable physical, mental, and psychosocial well-being.
For Resident #11, that meant the difference between being able to communicate his needs and remaining isolated by his speech difficulties, dependent on staff who had proven unwilling to provide the basic tool that could help him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Big Bend from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVIATA AT BIG BEND in PERRY, FL was cited for violations during a health inspection on September 11, 2025.
Resident #11 told inspectors on September 8 that he has trouble communicating.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.