Aviata At Big Bend

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to maintain a clean and comfortable environment for 7 of 16 sampled occupied resident rooms. (Rooms # 100, #105, #201 #202, #206, #305, and #401)The findings include:room [ROOM NUMBER] On 3/23/26 at approximately 11:30 AM, room [ROOM NUMBER] was observed with a resident on a pillow with numerous small tears and a dinner plate sized hole with exposed inner foam stained brownish yellow. There was no pillowcase on the pillow. The wardrobe was observed to have a door hanging off the hinge with the sleeve of a long-sleeved shirt draped over the top through the gap. The dresser had exposed particle board along the top border of each drawer. The privacy curtain was soiled with multiple reddish-brown splotches. A follow up observation was conducted in room [ROOM NUMBER] with the Staff F/Registered Nurse. The soiled and ripped up pillow was observed resting on the seat of a wheelchair beside the resident's bed. Staff F observed the pillow and stated the damaged and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews and record review, the facility failed to develop a smoking care plan to address smoking supervision and assistance requirements for 1 of 3 residents sampled for smoking. (Resident #11)The findings include:Resident #11 was observed smoking in the designated smoking area with staff supervision on 3/24/26 at approximately 1:25 PM and on 3/25/26 at approximately 9:34 AM and 3:33 PM. The facility supplied a resident smoker list on 3/23/26 with Resident #11 on the current list.A review of the resident's care plan revealed no care plan or interventions related to smoking and the resident requiring assistance with personal care due to weakness. A list of the resident's evaluations revealed one smoking evaluation completed on 2/20/26 at 3:39 PM.A review of the resident's progress notes from the Nurse Practitioner, with the date of 12/22/25, revealed the nicotine patch was discontinued due to the resident's smoking.An interview was conducted with Employee J (certified nursing assistant (CNA)) on 3/24/26 at approximately 1:30 PM, who indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident record reviews, and review of the facility's policy and procedure, the facility failed to implement their policy and procedure to ensure residents were provided with education of the risk and benefits of the vaccine and offered the COVID-19 vaccine in accordance with current CDC (Center for Disease Control and Prevention) guidelines for 4 of 5 residents sampled for immunizations. (Residents #20, #28, #29, and #32)The findings include: On 03/24/2026, a record review was conducted for Resident #20. The record revealed documentation on 03/05/2024 that the resident refused the COVID-19 vaccine. There was no documentation to indicate if the resident was provided with education or offered the 2025/2026 COVID-19 vaccine.On 03/25/2026, a record review was conducted for Resident #28 record revealed no documentation on COVID-19 consent, education, or documented offer of the COVID-19 vaccine to Resident #28 since the resident was admitted on [DATE]. There was no documentation indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure a functioning call light system in the bathroom that could be activated from the floor for 2 of 2 sampled residents. (Residents #4 and #23)The findings include:On 3/24/26 at approximately 3:00 PM, an observation of a bathroom shared between Resident #4 and Resident #23 revealed a call light cord approximately 2 inches long by the toilet and not reachable from the floor in the event of a fall.An interview was conducted on 3/24/26 at approximately 3:05 PM with Employee G, Registered Nurse (RN). She confirmed the call light cord was too short to be activated by residents if they were on the floor following a fall. The RN indicated she would submit a work order for maintenance to address the concern.An interview was conducted on 3/25/26 at approximately 9:33 AM with the Maintenance Director that confirmed the call light cord was too short and required replacement. The Maintenance Director indicated the staff should submit work orders when repairs are needed and he had not been notified of the issue.

Based on interviews and record review, the facility failed to protect residents from abuse for 1 of 7 residents sampled for abuse. (Resident #1)The findings include: On 2/10/26 at approximately 12:00 PM, an interview was conducted with Resident #1, who stated that, on 1/19/26, Staff A, Registered Nurse (RN) entered his room speaking loudly, stating that he is a liar and he is going to get her mom written up. Resident #1 went on to state that the Social Worker Aide (SWA) was present and instructed Staff A to leave the room. Resident #1 went on to state he did not receive a bath on 1/19/26 and 2/3/26 and felt he was being retaliated on from Staff A. Resident #1 stated on another occasion after 1/19/26, Resident #5 was in his (Resident #1) room visiting when Staff A entered his room yelling. Staff A stated she heard him talking about her and to keep her name out of his mouth. Resident #1 stated he wrote a grievance on the missing baths and reported the verbal abuse from Staff A to the Administrator and the Director of Nursing (DON).On 2/10/26 at approximately 1:00 PM, an interview was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to immediately identify and report an allegation of verbal abuse for 1 of 7 residents sampled for abuse. (Resident #1).The findings include:On 2/10/26 at approximately 12:00 PM, an interview was conducted with Resident #1, who stated that, on 1/19/26, the Social Worker Aide (SWA) was present while Staff A, Registered Nurse (RN), entered his room yelling at him. Resident #1 stated he reported the verbal abuse from Staff A and the feeling of retaliation to the Administrator and the Director of Nursing (DON).On 2/10/26 at approximately 3:35 PM, an interview was conducted with the DON, who stated he spoke to the Administrator about the allegation of verbal abuse on 1/19/26 and was under the impression that the Administrator reported to the state agencies on 1/19/26.On 2/10/26 at approximately 4:00 PM, an interview was conducted with the Administrator, who stated she had been informed of the allegation on 1/19/26. The Administrator went on to say she did not report the abuse to the state agency, stating she did not feel it was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure a thorough investigation was conducted of the allegation to protect residents for 1 of 7 residents sampled for mandated reporting. (Resident #1)The findings include:On 2/10/26 at approximately 3:10 PM, an interview was conducted with the Social Service Director (SSD) who stated on 1/19/26 she reported the abuse allegations made by Resident #1 to the Administrator, who is also the facility's abuse coordinator, and felt the allegations were verbal abuse and Staff A needed to be suspended. On 2/10/26 at approximately 4:40 PM, an interview was conducted with the Human Resource Director (HRD), who stated on 1/19/26, while in morning meeting, she heard the SSD report the abuse allegations to the Administrator and that Staff A needed to be suspended. The HRD stated she also went to the Administrator and told her Staff A needed to be suspended. The HRD stated she began a workplace investigation on 1/19/26 and Staff A was terminated on 2/9/26.On 2/10/26 at approximately 4:45 PM, an interview was conducted with Resident #1,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews, the facility failed to provide adequate supervision to prevent incidents for 1 to 1 monitoring for 1 of 3 residents. (Resident #1)The findings include:On 8/5/25 at 10:35 AM, during the tour of hall 100, observed Staff Member C (Director of Patient Experience) sitting in the hallway. She was assigned 1:1 monitoring for Resident #3. It was noted that Staff C could not observe Resident #3 for 1:1 due to the door being closed. On 8/6/25 at approximately 3:45 PM, a follow up observation of Hall 100 was performed. Staff Member C was in the hall and assigned to be on 1:1 observation for Resident #3. However, it was not possible to see Resident #3 due to the door only being slightly open with the privacy curtain pulled. On 8/6/25 at approximately 9:24am, an interview was performed with the Regional Nurse about 1:1 procedures. She stated that the facility does not have a 1:1 policy in place. On 8/6/25 at approximately 4:44 pm, an interview with the LPN MDS Coordinator was performed. She was asked about any training for 1:1 procedures for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure policies were upheld regarding smoking to ensure safety for 6 of 6 residents reviewed for smoking (Resident #42, #37, #65, #36, #6, #30). The findings include: Resident #42 During a tour of the facility conducted on 12/16/24 at 12:20 PM, the surveyor observed Resident #42 sitting at the side of her bed with a vape hanging from a lanyard around her neck. An interview was conducted with Resident #42 at this time. The resident was asked if the facility allowed her to keep her vape on her or if the staff was supposed to keep it for her. Resident #42 shrugged her shoulders in response. A review of Resident #42's record revealed she was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #42 has a medical history significant for Lack of Coordination, Communication Deficit, Muscle Weakness, and Tremor. Review of Resident #42's Quarterly Minimum Data Set (MDS) dated [DATE] documented she had a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to provide a sanitary environment in the dining rooms, laundry area and one residential room. The findings include: On 12/16/24 at 11:40 AM, a tour of the dining and kitchen area was conducted. The floor in the kitchen area had several spills of what appeared to be liquid that was now dry and dry food and crumbs were observed at every table. There were some red stains as well. (Photographic evidence obtained) On 12/16/24 at 11:46 AM, an interview with Staff C, Dietary Aide, was performed. When asked her opinion on the condition of the floors, she stated they were disgusting and unacceptable. When asked who was responsible for keeping the floors clean she stated that someone from laundry across usually sweeps and mops but she was unaware why it had not been done. On 12/16/24 at 11:59 AM, an interview was conducted with Staff D, Licenced Practical Nurse Unit Manager. She was assisting in the dining room that day. When asked her opinion on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of records, and policy review, the facility failed to ensure 2 of 3 residents sampled received restorative nursing as recommended. (Resident #31 and #55) The findings include: Resident #31 On 12/16/24 at approximately 12:45 PM, Resident #31 was noted to have his left arm, wrist, and hand contracted. There was a splint lying on his bedside table. On 12/16/24 at approximately 3:52 PM, Resident #31 was observed without a splint in place. The splint was lying on his bedside table. The resident was asked if that splint was for his wrist and hand. He nodded yes in agreement indicating that the brace was for his left arm, wrist, and hand. On 12/17/24 at approximately 8:50 AM, Resident #31 was observed without his splint on. On 12/17/24 at approximately 11:51 AM, Resident #31 was observed up in his wheelchair watching television in a common area. He did not have a brace on at the time of the observation. On 12/17/24 at approximately 3:21 PM, Resident #31 was observed awake in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure physician orders for tube feeding were followed and failed to ensure tube feeding was administered in a proper manner for 1 of 1 resident reviewed for tube feeding. (Resident #242) The findings include: During a tour of the facility conducted on 12/16/24 at 11:53 AM, Resident #242 was observed with a tube feeding bag. Closer observation revealed there were no labels, date, time, or tube feeding formulary written on the bag. The tube feeding machine was set for the tube feeding to instill at 60 milliliters per hour (mL/hr) and for the water flush to instill at 100mL every 2 hours (photographic evidence obtained). The initial record review for Resident #242 revealed that the physician orders for tube feeding included an order written on 12/03/24 for Jevity 1.5 60ml/hr X [run for] 24 hours and an order written on 11/18/24 for Flush g-tube [feeding tube] with 100mL of water every 6 hours for hydration. Resident #242 was admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, the facility failed to post nursing staffing in an accessible location that included the required information daily on 1 of 3 survey dates. (12/16/2024) The findings include: On 12/16/24 at approximately 12:00 PM, during an observation, no staffing was posted as required anywhere in the facility. The dry eraser board in both the east and west wing did have a date and the total number of actual hours worked by staff, but it was not posted in a clear and readable format in a place accessible to residents and visitors. On 12/16/24 at approximately 1:00 PM, Staff Member M, a Certified Nursing Assistant (CNA), was asked to show where staffing was posted. She indicated that it should be posted on the dry erase board but acknowledged that it was not complete. (photographic evidence was obtained). On 12/17/24, staffing information was posted as required. On 12/18/24 at approximately 2:00 PM, an interview was conducted with the Staffing Coordinator Scheduler was conducted. She was asked to show where staffing was posted on 12/16/24. She initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment and ensure sufficient hot water in 6 of 16 sampled resident rooms. (Rooms 110, 206, 207, 212, 214, and 216) The findings include: An observation of room [ROOM NUMBER] was conducted on 10/2/23 at 2:43 PM. The overbed table was missing the plastic border and had exposed rough edges. In addition, the bathroom had a rusted toilet riser and peeling paint on the wall. (Photographic evidence obtained.) It was further discovered that after the hot water ran in the bathroom sink for approximately 3 minutes, the water did not get warm. An interview was conducted with Resident #51 at this time, and she stated they have not had any hot water in the bathroom since Hurricane Idalia about a month ago. An observation of room [ROOM NUMBER] was conducted with the Administrator on 10/4/23 at 2:32 PM. She observed and confirmed the peeling paint in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.