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Gracy Woods Nursing Center: Broken Arm Left Unplanned - TX
Resident #1 fell on October 16, 2025, breaking her right humerus....
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Resident #1 fell on October 16, 2025, breaking her right humerus....
The violation occurred on October 16 at 12:34 PM on Hall 500 at Pflugerville Care Center....
Federal inspectors found staff transferring residents without gait belts during a September complaint investigation....
The investigation began when corporate auditors discovered the manager was not following proper procedures for distributing resident funds....
The incident occurred on the evening of October 19 when Resident #2 stomped or kicked Resident #1's foot at Avir at Overton....
But when federal inspectors reviewed the records in November, they found gaps in documentation and a facility that couldn't produce basic intake records....
The patient experienced shortness of breath during exertion, at rest, and while lying flat....
The November 9 assault was the second documented incident in two weeks....
At 11:13 a.m., 4:15 p.m., and 4:45 p.m., they found the same brown and yellow removable substance on the toilet seat and metal safety rail....
But when she fell again on October 30, staff discovered they had been disregarding the safety protocols entirely....
The resident said the guard "curls his lips and mean mugs" them, and "puts hand on the gun in front of" them as intimidation....
Four additional days had no documentation recorded for the evening shift at all....
The resident had severe cognitive impairment according to facility assessments....
The resident had been placed on the intensive monitoring protocol after being identified as high-risk for falls....
Federal inspectors observed the violations during wound care procedures at Mesa Vista Inn Health Center in October....
The resident, a stroke survivor who has lived at the facility for two years, told inspectors on October 20 that staff had left one of the cans in his room....
The medication was supposed to be stored between 68 and 77 degrees....
The tampering went undetected for months....
Resident 34 at Altercare Newark South had requested the shower for Friday morning, November 14th, before her scheduled medical procedure....
Without access to these devices, residents faced the choice of attempting dangerous tasks alone or waiting indefinitely for staff to check on them....