EASTLAND, TX - The Woodlands nursing facility faced immediate jeopardy citations after multiple security failures including resident elopements through unlocked windows and unsafe van transportation that resulted in injuries.
Federal inspectors identified critical supervision lapses that placed vulnerable residents at risk of serious harm. The April 2025 complaint investigation revealed systemic failures in the facility's ability to protect residents in their memory care unit and during off-site transportation.
Resident Escapes Through Bedroom Window
The most serious incident occurred when a resident with traumatic brain injury climbed out of an unlocked bedroom window and was found wandering near a dialysis center. The resident had been placed in the facility's secure memory care unit specifically due to repeated exit-seeking behaviors and elopement attempts.
The facility's medical director confirmed the resident was not capable of making independent decisions due to brain injury and faced significant danger if found alone outside the facility, particularly given its location on a major highway. Vehicle traffic posed a substantial risk to any resident who might wander into the roadway.
Despite being classified as high-risk for elopement, the facility failed to secure the resident's bedroom window with proper locks. When maintenance was initially requested to install window locks in February 2025, the work was never completed or verified by administration.
Pattern of Exit-Seeking Behaviors Ignored
Medical records documented extensive exit-seeking behaviors spanning months before the successful elopement. The resident had previously:
- Scaled a 4-foot fence between the secure unit and adjacent patio area - Held exit doors open for the required 15 seconds to trigger emergency releases - Physically confronted staff who attempted to prevent exit attempts - Damaged exit doors and windows during escape attempts
Progress notes revealed the resident explicitly told staff "I can leave if I want to" and "I'm walking out of here tomorrow." Despite these clear warnings and documented attempts, the facility failed to implement adequate preventive measures.
Inadequate Staffing in Memory Care Unit
Inspectors found only one staff member working the entire secured memory care unit during evening shifts. This single caregiver was responsible for multiple residents with complex behavioral needs, including the elopement-risk resident.
The lone staff member acknowledged that responding to emergencies would require either leaving residents unattended or abandoning the secure unit to seek help from other areas. This staffing model created dangerous gaps in supervision for vulnerable residents who required constant monitoring.
Van Transportation Safety Failures
A separate immediate jeopardy citation involved unsafe wheelchair transportation that resulted in a resident sustaining a 25-centimeter abrasion to his lower back. Multiple residents reported feeling unsafe during facility van transportation, stating the vehicle was "not in good condition."
Safety assessments conducted after the injury incident revealed four residents expressed concerns about van transportation safety. One injured resident specifically cited inadequate staff training as a contributing factor to his injury.
The facility suspended the van driver pending investigation and implemented emergency retraining for all transportation staff. New protocols included:
- Mandatory competency testing for wheelchair securement procedures - Hands-on demonstrations of proper seatbelt application - Emergency response training for transport-related incidents
Medical Risks of Elopement
Elopement poses severe medical risks for residents with cognitive impairment or mobility limitations. Residents who wander unsupervised face risks including:
- Exposure-related injuries from weather conditions - Traffic accidents when wandering near roadways - Falls and trauma due to uneven terrain or obstacles - Medication interruption leading to medical complications - Dehydration and exhaustion from prolonged wandering
The traumatic brain injury affecting the eloping resident created additional vulnerabilities. Such injuries often impair judgment, spatial awareness, and problem-solving abilities, making independent navigation extremely dangerous.
Industry Standards for Memory Care Security
Established protocols require memory care facilities to:
- Conduct comprehensive risk assessments for all residents upon admission - Implement physical security measures including locked windows and monitored exits - Maintain adequate staffing ratios to ensure continuous supervision - Develop individualized intervention strategies for residents with exit-seeking behaviors - Regular safety monitoring of all potential egress points
The facility's wandering and elopement policy acknowledged these requirements but failed in implementation. Written protocols existed for identifying at-risk residents and developing safety interventions, but execution proved inadequate.
Transportation Safety Requirements
Federal regulations mandate nursing facilities ensure resident safety during all transportation activities. This includes:
- Proper vehicle maintenance and safety equipment functionality - Trained personnel competent in wheelchair securement techniques - Emergency response protocols for transportation incidents - Regular competency assessments for all transport staff
Van transportation requires specialized equipment and training to safely secure wheelchairs and protect residents during transit. Improper securement can result in serious injuries during normal vehicle operation or emergency situations.
Facility Response and Corrective Actions
Following the immediate jeopardy citations, the facility implemented emergency measures:
- Installed locks on all memory care windows to prevent unauthorized exits - Increased staffing levels in the secure unit during all shifts - Suspended van operations until safety protocols could be verified - Conducted comprehensive staff retraining on elopement prevention
The elopement-risk resident was transferred to a more secure facility better equipped to handle his specific behavioral needs. All memory care residents received updated safety assessments and revised care plans.
Transportation services resumed only after:
- Complete vehicle inspection and maintenance verification - Staff competency testing for all van drivers and transport aides - New safety protocols for wheelchair securement procedures - Emergency response training for transport-related incidents
Regulatory Outcomes
Federal inspectors removed the immediate jeopardy status after verifying implementation of corrective measures. However, the facility remained under enhanced monitoring to ensure sustained compliance with safety requirements.
The investigation resulted in citations for failing to provide adequate supervision to prevent accidents and unsafe transportation practices. Both violations carried immediate jeopardy severity levels due to the substantial risk of serious injury or death.
Ongoing Safety Concerns
The incidents highlight broader challenges in memory care security and the need for robust safety systems. Facilities must balance resident rights and dignity with necessary security measures to prevent dangerous situations.
Transportation safety requires ongoing vigilance and regular training updates as equipment and procedures evolve. Vehicle maintenance, staff competency, and emergency preparedness must receive continuous attention to protect vulnerable residents during necessary medical appointments and activities.
Families considering memory care placement should inquire about specific security measures, staffing ratios, and transportation protocols to ensure their loved ones receive appropriate protection while maintaining quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eastland Nursing & Rehabilitation from 2025-04-02 including all violations, facility responses, and corrective action plans.
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