Autumn Leaves Nursing And Rehab Inc
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
B looked at the bed wheels of Resident #1's bed and said we forgot to lock the bed. CNA B said the bed wheels should have been locked before the bed was raised, before the incontinent care (which required turning Resident #1 side to side) and before raising her up in the bed. CNA B said not ensuring the bed wheels were locked placed Resident #1 at risk of falling out of bed and also placed the staff at risk of injury.
During an interview on 10/23/25 at 11:53 AM, CNA A was asked if she should have done anything differently during the incontinent care and repositioning of Resident #1. CNA A looked at the bed wheels of Resident #1's bed and said she forgot to lock the bed. CNA A said before turning Resident #1 side to side,
in the bed and before raising Resident #1 up in the bed she (CNA A) should have ensured the bed wheels were locked. CNA A said not ensuring the bed wheels were locked could have caused the bed to slide
during the repositioning and could have resulted in Resident #1 falling out of the bed. During an interview
on 10/23/25 at 12:39 PM, the DON said CNA A and CNA B should have double checked to ensure the bed wheels were locked before moving and repositioning Resident #1. The DON said staff had to lock the bed
before providing care to any resident while they were in bed and before repositioning any resident in the bed. The DON said the CNAs body weight or the resident's body weight shifting while the bed was not locked could result in a resident falling out of the bed or staff falling themselves. During an interview on 10/23/25 at 1:20 PM, LVN D said CNA A and CNA B should have ensured the bed wheels were locked
before moving the resident in bed. LVN D said not ensuring the bed wheels were locked before moving Resident #1 could have caused her to fall out of the bed and also put the CNAs at risk of injury. During an
interview on 10/23/25 at 1:30 PM, the Administrator said he expected staff to ensure bed wheels were locked before repositioning or turning a resident. The Administrator failing to do so could result in serious injury to the resident. Record review of the facility's, undated, policy procedure titled, Routine Resident Care, stated .Care is taken to maintain resident safety at all times.(10) Staff members should observe the following safety precautions with all residents: a. Equipment with wheels (beds, wheelchairs, and other equipment) should be in the locked position when not moving.
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AUTUMN LEAVES NURSING AND REHAB INC in HENDERSON, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HENDERSON, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AUTUMN LEAVES NURSING AND REHAB INC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.