Aviata at Big Bend

Inspectors wroteBased on interviews and record review, the facility failed to honor and respect resident rights of choices and preferences of care for 1 out 4 residents reviewed. (Resident #1)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased on interviews and record review, the facility failed to protect residents from abuse for 1 of 7 residents sampled for abuse. (Resident #1)

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased on observations, record reviews, interviews, and policy reviews, the facility failed to prevent abuse and neglect resulting in an elopement for two residents (Residents #1 and #2) while in a secured and locked unit and while Resident #2 was under one-to-one supervision creating a potential for serious injury or death for both residents. The facility failed to prevent neglect for Resident #3, who was immobile and left in her room with the body of her deceased roommate for three hours resulting in serious psychosocial harm. The facility failed to prevent abuse by Resident #4, who suffered injuries from self-harm and was removed from the facility because of physical aggression toward a staff member while under one-to-one supervision. The cumulative effect of the failures resulted in potential for abuse and/or neglect for 85 out of 85 residents. [...]

Inspectors wroteBased on interviews, records reviews, a review of the facility QAPI (quality assurance and performance improvement) plan, facility assessment, and event investigation documents, the facility failed to maintain an effective QAPI program to ensure the supervision of residents at risk for elopement, self-harm, and aggressive behaviors (Residents #1, #2, and #4). Cross reference F600, F689. These failures resulted in substandard quality of care at the Immediate Jeopardy level beginning on 8/8/2025. The facility's QAPI committee failed to perform and/or document analysis of events following the elopement while under one-to-one supervision for Resident #2. [...]

Inspectors wroteBased on record reviews, interviews, and policy reviews, the facility failed to provide adequate supervision for residents identified as high risk for elopement for 2 out of 14 vulnerable residents (Residents #1 and #2) and for one resident identified as physically aggressive towards self, staff, and residents (Resident #4). The facility failed to provide supervision to prevent an unwitnessed exit from the facility for Resident #1 and Resident #2 on 8/30/2025 while Resident #2 was assigned to one-to-one (1:1) supervision and both Residents #1 and #2 were located on a secured, locked unit of the facility. [...]

Inspectors wroteBased on interview, observation, record, and policy reviews, the facility failed to implement care plan interventions for 4 residents (#1, #2, #5, and #11). Resident #11 was negatively impacted by the failure to implement the care plan to assist the resident in communicating his emotional, intellectual, physical, and social needs. The facility's failure to implement care plans related to adequate supervision for residents #1, #2, and #4 resulted in their ability to exit the facility for residents #1, #2, and #4 and for Resident #4 to cause physical injury to himself and others. Cross reference F600, F689.

Inspectors wroteBased 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)

Inspectors wroteBased 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).

Inspectors wroteBased on observation, record review, and interview the facility failed to provide a sanitary environment in the dining rooms, laundry area and one residential room.

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)