Autumn Leaves Nursing And Rehab Inc
AUTUMN LEAVES NURSING AND REHAB INC in HENDERSON, TX — inspection on November 26, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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