Aviata at Big Bend

In the surveyor’s words

From the most serious findings on record at Aviata at Big Bend, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Sep 11, 2025

  Based 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. […]

• Immediate jeopardy, widespreadF865Sep 11, 2025

  Based 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. […]

• Immediate jeopardy, patternF689Sep 11, 2025

  Based 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. […]

• Actual harm, patternF656Sep 11, 2025

  Based 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.The findings include:Resident #1 and #2 A record review for Resident #1 included diagnoses of chronic kidney disease stage 3, hyperlipidemia, generalized anxiety, hypertension, Atrial… […]

• No harm, potential for more than minimal, patternF584Mar 26, 2026

  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. […]