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Autumn Leaves Nursing And Rehab Inc

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About Autumn Leaves Nursing And Rehab Inc

General Information

Legal Business NameAutumn Leaves Nursing And Rehab Inc
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJune 18, 2004 (12 years)
Capacity125
Residents109
Percent Occupied87%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Autumn Leaves Nursing And Rehab Inc

Autumn Leaves Nursing And Rehab Inc
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

November 5, 2015 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
FManyPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
GFewActual HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmComplaint+InspectionCoordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
ESomePotential for HarmHealth InspectionEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

November 3, 2015 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
FManyPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.

September 3, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintHonor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States.

September 11, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
FManyPotential for HarmHealth InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
ESomePotential for HarmHealth InspectionProvide food in a way that meets a resident's needs.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmComplaint+InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
CManyPotential for Minimal HarmHealth InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.

September 9, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.

July 10, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$1,365 fine
FManyPotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
FManyPotential for HarmComplaintProtect each resident from all abuse, physical punishment, and involuntary separation from others.
FManyPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Autumn Leaves Nursing And Rehab Inc require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 35min
2hr 25min
ReportedExpected
CNA
55min
35min
ReportedExpected
LPN
15min
60min
ReportedExpected
RN
3hr 45min
4hr
ReportedExpected
Total Nursing

This facility also provides approximately 10min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

91.9%
92.5%
92.5%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
66.7%
61.5%
64.9%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
73.5%
-
82.4%
46.9%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
11.3%
11.7%
9.8%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
20.5%
17.6%
29.0%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
7.3%
14.4%
12.5%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
5.1%
10.5%
7.4%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
8.5%
7.4%
0.0%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
3.3%
1.2%
3.4%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
9.2%
7.4%
6.4%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
3.0%
4.2%
2.1%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
0.0%
0.0%
0.0%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

12.6%
18.2%
16.1%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
20.7%
20.7%
20.7%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
24.6%
26.9%
37.5%
16.5%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
1.6%
1.6%
1.7%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
0.0%
0.0%
0.9%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened