Autumn Leaves Nursing: Dialysis Access Site Failures - TX
The nurse, identified in inspection records only as RN A, worked at the dialysis center where Resident 1 received treatment. She told inspectors she had warned the nursing home that leaving dressings on the vascular access site between dialysis sessions could cause clotting. She said she saw it happen not once, but multiple times. The same dressing, applied at the dialysis center, still in place when the resident came back for her next appointment.
The access site in question was an AV shunt, a surgically created connection between an artery and a vein that allows blood to be drawn out, filtered through a dialysis machine, and returned to the body. It is the lifeline for anyone on hemodialysis. Keeping it clear and functional is not optional.
Autumn Leaves Nursing and Rehab did not remove the dressings as directed. Inspectors cited the facility under federal tag F698, which covers the provision of specialized services, and noted the level of harm as minimal harm or potential for actual harm, with some residents affected.
The facility's own policy on hemodialysis care, which inspectors reviewed during the investigation, said the home would provide routine AV shunt care and monitoring per physician orders. What the policy said and what happened to Resident 1 were not the same thing.
The resident's responsible party, who visited frequently, told inspectors she had noticed the dressing on the arm during her visits. She said the facility only began removing the dressings after the resident started developing increased swelling in her arm. That detail, the swelling appearing before anyone changed course, is the clearest measure of how long the problem went unaddressed.
Inspectors tried to reach Resident 1 directly. They called on October 13 at 10:30 in the morning and again at 1:45 in the afternoon. Both times, the number came back disconnected or no longer in service. The responsible party later explained that the resident had discharged home with home health services and that her phone was broken.
The inspection was conducted in response to a complaint and completed November 18, 2025. It is not clear from the inspection record how many dialysis trips Resident 1 made with the dressing left in place, or for how long the pattern continued before the swelling prompted the facility to act. The dialysis nurse's account suggests it happened across more than one appointment cycle. The responsible party's account suggests the facility's response came only after a visible symptom appeared.
By the time inspectors documented the violation, Resident 1 was no longer at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Leaves Nursing and Rehab Inc from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
AUTUMN LEAVES NURSING AND REHAB INC in HENDERSON, TX was cited for violations during a health inspection on November 18, 2025.
The nurse, identified in inspection records only as RN A, worked at the dialysis center where Resident 1 received treatment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.