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Autumn Leaves Nursing: Unlocked Bed Safety Failure - TX
Neither checked that the bed wheels were secured before beginning the care....
Latest reports, citations, and penalties from CMS data
Neither checked that the bed wheels were secured before beginning the care....
The violations occurred despite facility policies requiring medications to remain accessible only to licensed nursing personnel and authorized staff members....
Yet when inspectors observed daily operations, they witnessed staff walking directly into the resident's room without following these procedures....
Federal inspectors discovered the omission during a complaint investigation in late October....
Resident 92 experienced severe foot pain on April 23, prompting staff at Arbors at Delaware to call the physician and request an emergency room transfer....
Instead, the resident missed seven consecutive doses between November 14 and November 17, according to federal inspection records....
Federal inspectors found the documentation failure at New Orange Hills during a complaint investigation in late November....
The incident at Avir at Beeville involved two residents, identified in the inspection report as R3 and R4....
The breakdown occurred with Resident 2, who was admitted in March 2025 with cognitive communication deficits, age-related cognitive decline, and epilepsy....
The anticoagulant thins blood, creating bleeding risks during surgery....
The November 19 incident at Rose Villa Health Care Center involved 11 different medications scheduled for 9 a.m....
But when inspectors arrived following a complaint in November, staff acknowledged the sentimental piece was gone....
Even then, the training was incomplete and poorly documented....
The violation occurred at Heritage Nursing & Rehabilitation during a November 26 inspection....
The November 28 inspection triggered the most severe federal enforcement action possible short of facility closure....
But when she found the skin irregularities on Resident #1, she made her own assessment that they didn't look suspicious....
That letter detailed behaviors that made the resident "feel upset," according to the administrator who received it....
State inspectors requested training documentation on three separate dates in December 2024 â November 30, December 1, and December 8....
The facility sent closure letters to families on September 25th and began discharging residents on October 1st....
The incident occurred at Creekside Village on September 26 when CNA A entered the resident's room at 11:30 AM to change her heavily soiled brief....