Aviata At Big Bend
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many
Another care plan was initiated on 1/11/2022 for elopement risk wanderer related to disorientation to place, impaired safety awareness, resident wanders aimlessly, significantly intrudes on the privacy or activities.
Interventions included: 1:1 supervision 24/7 for safety due to aggressive behaviors with others. DO NOT sit inside resident's room – sit in the doorway facing him so that he remains in your visual field – If he goes into the restroom, you are to stand by the door with it cracked, to ensure that he does not go through the door on the other side. This care plan was initiated on 3/12/2023 with a most recent revision on 9/8/2025. Other interventions include distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank) date initiated 1/11/2022.
A psychiatric progress note dated 8/17/2025 documented that “staff note that he becomes easily bored and that his attention fluctuates during interactions. His presentation remains consistent with chronic psychosis, with ongoing negative symptoms such as blunted affect and reduced motivation. Behavioral interventions have recently been introduced, focusing on structured reward-based strategies to encourage engagement and reduce maladaptive behaviors. Initial staff feedback suggests that he responds intermittently to these supports.” Another psychiatric noted dated 8/29/2025 noted “Staff report that the patient's attention fluctuates during interactions and that he becomes easily bored.”
A task list for one-to-one activities reviewed for past 30 days listed documentation for only the following days: 8/12/2025, 8/13/2025, 8/15/2025, and 8/20/2025. Resident #4 was observed to be on 1:1 observation with staff on 9/8/2025 (date of survey entry) and the date of this review was 9/9/2025 – no documentation identified for 9/9/2025.
The activities/participation (Question 2) documenting for each of the 4 dates that talking was the only activity used out of several listed which included arts and crafts, board games, exercise, games, gardening, meditation/relaxation, music, and others.
A progress note dated 8/15/2025 noted “Resident attacked PCA (patient care assistant) assigned to 1:1 with him. Resident was informed not to exit building and punched staff in chest. Staff member restrained resident to ensure safety and resident then head-butted him. PCA removed from 1:1, new 1:1 placed with resident.”
A psychiatric progress note date 8/18/2025 documented “The patient is seen today at the request of
the staff after a report of the patient hitting a staff member. Staff reports that the patient was informed not to exit building, and he responded aggressively and hit staff. The patient was temporarily restrained by holding his hands/arms in order to prevent him from further hitting the staff and once he was calm, his 1:1 CNA was changed out.”
A progress note dated 9/4/2025 at 5:40am documented “Resident was observed waking from sleep and immediately began pacing rapidly up and down the halls. Assigned CNA followed for supervision.
Resident began attempting to exit through the doors and became agitated. Resident [#4] went out the facility along with 3 other staff members. The other nurse on shift attempted to support the resident to prevent him from falling. During the intervention, the resident forcefully moved his head forward and made contact with nurse. Resident then attempted to leave the premises and fell into the bushes hitting his head.
Resident was noted with abrasions to his left forehead and left knee. Due to 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.”
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Big Bend
207 Marshall Dr Perry, FL 32347
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-Tag F0656
F 0656 Level of Harm - Actual harm
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.”
Residents Affected - Some
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Big Bend
207 Marshall Dr Perry, FL 32347
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-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Big Bend
207 Marshall Dr Perry, FL 32347
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-Tag F0865
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.
AVIATA AT BIG BEND in PERRY, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PERRY, FL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVIATA AT BIG BEND or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.