Pleasanton North Nursing: Fall Prevention Failures - TX
Inspectors cited Pleasanton North Nursing and Rehabilitation following a November 2025 complaint inspection for failing to follow its own fall prevention measures for a resident identified as being at risk for falls. The deficiency was tagged under care planning requirements and recorded as carrying potential for actual harm.
The finding turned on something specific and simple. The facility's own fall prevention training told staff to keep the beds of at-risk residents in a low position, as close to the floor as possible, so that if a resident fell, they would fall a shorter distance. The logic is straightforward: a person who drops from a raised hospital bed hits the ground harder than one who slides from a bed set low.
The Director of Nursing confirmed all of this on November 7, 2025. In an interview at 11:00 a.m., she said staff had received training on fall prevention that included keeping beds in the low position for residents at risk. She said every staff member was responsible for checking this. She said residents at risk for falls were identifiable because their rooms had a sign posted that read, simply, "low bed." She said the reason it mattered was that a resident "could fall and be injured."
The sign was there. The training had happened. The bed was not in the low position.
The facility's own care plan policy, dated 2025, states that the facility will develop and carry out a comprehensive, person-centered care plan for each resident that covers all services identified in their assessment. A fall risk designation, and the precautions that go with it, is exactly the kind of service that policy is meant to capture and enforce at the bedside, not just on paper.
What inspectors documented was the gap between those two things: the plan that existed and the room where it wasn't being followed.
This kind of deficiency rarely generates headlines. It carries no immediate jeopardy designation. The harm level recorded here is minimal, or potential for actual harm, meaning inspectors did not find that a resident had already fallen from the raised bed. That matters, and it is worth saying plainly. No injury was documented in this report.
But the conditions that produce documented injuries and the conditions documented here are often identical. A bed left in the raised position for a fall-risk resident is not a paperwork problem. It is the specific physical setup that fall prevention protocols exist to prevent. The training, the sign on the wall, the care plan policy — those systems were built because a raised bed and a fall-risk resident in the same room is a recognized hazard.
The Director of Nursing said it herself. They could fall and be injured.
Pleasanton North Nursing and Rehabilitation serves residents in Pleasanton, in Atascosa County, roughly 40 miles south of San Antonio. The inspection was conducted in response to a complaint, meaning someone, a resident, a family member, or a staff member, contacted authorities with a concern before inspectors arrived.
The report does not say how long the bed had been in the raised position, or how many times staff had entered that room without correcting it. It does not say whether the resident was aware of the risk or had asked for the bed to be adjusted. Those details were not recorded, or were not available.
What the report does establish is that a facility with a posted sign, trained staff, and a written policy still sent inspectors home with a finding that the bed was up when it was supposed to be down.
The Director of Nursing described a system that should have worked. Someone in that room, on that shift, let it not work. And the resident at risk for falls remained in a bed positioned to make a fall worse.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pleasanton North Nursing and Rehabilitation from 2025-11-24 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: August 26, 2026 · Our methodology
PLEASANTON NORTH NURSING AND REHABILITATION in PLEASANTON, TX was cited for violations during a health inspection on November 24, 2025.
The deficiency was tagged under care planning requirements and recorded as carrying potential for actual harm.
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.