Afton Oaks Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
and review the plan for removal. During an interview on 11/19/2025 with Interim ADM, DON, Traveling Corporate DON, ADON, SW, Maintenance Supervisor revealed staff in-person and or by telephone were in-serviced. Regional Corporate Compliance Nurse said if the employee or prn was not in serviced that staff employee cannot work their shift until all in-services were completed. During an interview on 11/19/2025 between 12:50 pm and 4:00pm with ADON, RN's ,B, E; Certified Occupational Therapy Assistant, 4-CMA's, D,F,G,H; 18-CNA's, I,J,K,L,M,N,O,P,Q,R,S,T,U,V,W,X,Y,Z; 2-Dietary Staff's, A, AA; 2-Facility Marketing Admission's, BB, CC; 1-Facility Director of Nursing, Laundry staff, LVN Charge Nurse's, DD, EE, FF, GG, HH, Social Worker indicated that employees had received training on elopement prevention and the steps to follow when a resident attempts to leave the building. Staff consistently reported that all exterior doors are equipped with a 15-second delayed-egress system that triggers an alarm when engaged. Staff stated they are expected to investigate all alarms immediately. Staff described their responsibilities when a resident approaches or exits through a monitored door. They stated they are to remain with the resident, attempt redirection when appropriate, and contact the charge nurse for assistance. Staff explained that if a resident cannot be located, nursing leadership initiates a search and determines whether the resident had signed out or otherwise been approved to leave the facility. Staff reported that the administrative staff, the DON/ADON, the residents' provider, and the responsible party are notified according to facility protocol. Staff also noted the presence of an Elopement Risk Binder at each nurse's station and the front desk. They stated this resource contains relevant information to support staff
during search efforts. The staff in-services revealed interventions such as toileting, offering fluids or snacks, and addressing comfort to redirect residents. Staff stated if additional help is needed, they contact the nurse charge or nursing administration. The information provided was consistent with staff and aligned with
the facility's in-service training conducted November 18, 2025, and November 19, 2025. The Regional Corporate Compliance Nurse, DON, Interim Administrator, Traveling DON, ADON were informed the immediate jeopardy was removed. While the IJ was removed on 11/19/25 at 4:33 pm. The facility remained out of compliance with a severity of no actual harm with potential for more than minimal harm that was not
an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of
the corrective system.
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Afton Oaks Nursing and Rehabilitation Center in Houston, 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 Houston, 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 Afton Oaks Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.