Aviata At Big Bend

continued attempts to leave the facility and inability of staff to maintain control, law enforcement was contacted.

Resident [#4] was redirected back into the facility prior to their arrival.

Police arrived shortly thereafter.

Resident[#4] continues to be combative and agitated.”

Resident #11 On September 8, 2025 at 3:15 PM, Resident #11 shared that he has difficulty communicating.

His roommate offered that he has asked the staff to get Resident #11 a communication board several times, but they have not. Resident #11 confirmed that he has never received one.

When asked how it would assist, he stated that because of his communication difficulties, it would help him to let the staff know what he needs.

No communication board was seen in the resident's room.

On September 9, 2025 at 10:25 AM, a review of the care plan for Resident #11 (last reviewed 6/23/25) shows a focus area of the resident being dependent on staff for meeting emotional, intellectual, physical, and social needs.

The goal of the resident was maintaining involvement in cognitive stimulation and social activities as desired.

Interventions included, All staff to converse with resident while providing care; Assist with arranging community activities; Arrange transportation; Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and age appropriate; Invite the resident to scheduled activities; providing a Community Life calendar; notifying resident of any changes to the calendar of activities; thanking resident for attendance at Community Life functions; assisting/escorting to Community Life functions; providing bedside/in-room visits and activities if unable to attend out of room events.

Also included in interventions in a note stating Resident #11 has a communication board but can communicate without it if given time.

Another focus area is communication problems related to aphasia.

One of the interventions is to evaluate the resident for dexterity/ability to use communication board, writing, use of computer, or use of sign language as alternate communication to speech.

Also included is to refer to speech therapy for evaluation and treatment as ordered.

The date of initiation is 01/21/2022.

On September 9, 2025 at 12:10 PM, a review of the resident's orders since admission reveal no order for speech, occupational therapy, physical therapy, or evaluation.

On 9/9/25 at 12:18 PM, the MDS Coordinator was asked for evidence of referral to speech therapy as documented in the care plan.

The MDS Coordinator was unable to locate the referral.

She called the Therapy Director for the facility's contracted speech therapy, and the director was unable to locate a referral or any visit notes.

The MDS Coordinator was asked if the referral or communication board was followed up on, and she stated that it doesn't look like it was.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Big Bend

207 Marshall Dr Perry, FL 32347

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

so clear that he can't manage his voices and they said that is a good idea. It takes specialized people to help to take care of them. I was talking to another resident and he said, ‘that guy was standing over me in my bed the other day – is he violent?' And the nurse came and they are all scared of him, I know that's true.” On 9/11/2025 at approximately 9:50am, an interview took place with the Administrator, the RVPO, and the RDCS regarding the facility's ability to meet the needs for safety for Resident #4 and why the facility continues to readmit Resident #4 after multiple discharges related to aggression and exiting the facility in which an involuntary psychological examination was ordered.

The RVPO said that they have discussed it and reached out to the Long-Term Care Ombudsman and other facilities who refuse to accept Resident #4, and they take him back because “we'll be in trouble with the state if we don't.” The Administrator was asked about the discharge notice signed on July 4, 2025, which she signed and documented that Resident #4's needs could not be met at the facility and what had changed in Resident #4's condition or the services offered by the facility that indicated his needs could be met at the facility.

The response was that “he's our resident and we have to take him back.” During the interview, copies of documentation of communication with the Ombudsman and requests to other facilities to accept Resident #4 were requested but not provided.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Big Bend

207 Marshall Dr Perry, FL 32347

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited AVIATA AT BIG BEND in PERRY, FL for a deficiency under regulatory tag F-F0865 during a complaint investigation conducted on 2025-09-11.

Category: Administration Deficiencies

The facility was found deficient in the following area: Have a plan that describes the process for conducting QAPI and QAA activities.

Scope/Severity Level L: widespread, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 4 deficiencies cited during this inspection of AVIATA AT BIG BEND.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-10.