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AUTUMN LEAVES NURSING AND REHAB INC

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AUTUMN LEAVES NURSING AND REHAB INC is a government - hospital district facility in HENDERSON, TX with 125 certified beds and a 3-star overall CMS rating. The facility has 32 deficiency records on file. Total penalties: $30K.

321 KILGORE DRIVE, HENDERSON, TX 75652

Phone: 9036571923

Overall Rating

3/5

Health Inspection

3/5

Staffing

1/5

Quality Measures

5/5

Long-Stay Quality

5/5

Facility Information

Provider Number
676025
Ownership
Government - Hospital district
Provider Type
Medicare and Medicaid
Beds
125
Residents
99
In Hospital
No
County
Rusk
Last Inspection
Mar 19, 2025

Staffing Data

RN Hours
0.23 (nat'l avg: 0.68)
LPN Hours
0.81
CNA Hours
1.94
Total Nursing Hours
2.99 (nat'l avg: 3.89)
PT Hours
0.04
Nursing Turnover
53.6%
RN Turnover
37.5%

What the CMS Record Reveals About AUTUMN LEAVES NURSING AND REHAB INC

AUTUMN LEAVES NURSING AND REHAB INC operates 125 certified beds in HENDERSON, TX with approximately 99 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (1★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 32 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $30K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 2.99 total nursing hours per resident day (national average 3.89), with RN coverage at 0.23 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "Government - Hospital district" ownership and operating as a "Medicare and Medicaid" provider, AUTUMN LEAVES NURSING AND REHAB INC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 53.6%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (32 most recent)

D — Isolated - Minimal harm Nov 26, 2025 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 28, 2025

E — Pattern - Minimal harm Nov 18, 2025 Tag: 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 20, 2025

E — Pattern - Minimal harm Mar 19, 2025 Tag: 0921

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Category: Environmental Deficiencies

Corrected: Apr 15, 2025

E — Pattern - Minimal harm Mar 19, 2025 Tag: 0558

Reasonably accommodate the needs and preferences of each resident.

Category: Resident Rights Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0881

Implement a program that monitors antibiotic use.

Category: Infection Control Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Apr 15, 2025

E — Pattern - Minimal harm Mar 19, 2025 Tag: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Category: Pharmacy Service Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Category: Pharmacy Service Deficiencies

Corrected: Apr 15, 2025

E — Pattern - Minimal harm Mar 19, 2025 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Apr 15, 2025

E — Pattern - Minimal harm Mar 19, 2025 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0693

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0641

Ensure each resident receives an accurate assessment.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Mar 19, 2025 Tag: 0561

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Category: Resident Rights Deficiencies

Corrected: Apr 15, 2025

D — Isolated - Minimal harm Sep 17, 2024 Tag: 0573

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Category: Resident Rights Deficiencies

Corrected: Oct 2, 2024

E — Pattern - Minimal harm Jun 27, 2024 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 12, 2024

E — Pattern - Minimal harm Jan 31, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Feb 26, 2024

D — Isolated - Minimal harm Jan 31, 2024 Tag: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Category: Pharmacy Service Deficiencies

Corrected: Feb 26, 2024

E — Pattern - Minimal harm Jan 31, 2024 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Feb 26, 2024

D — Isolated - Minimal harm Jan 31, 2024 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Feb 26, 2024

D — Isolated - Minimal harm Jan 31, 2024 Tag: 0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category: Resident Rights Deficiencies

Corrected: Feb 26, 2024

D — Isolated - Minimal harm Jan 31, 2024 Tag: 0942

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Category: Resident Rights Deficiencies

Corrected: Feb 26, 2024

D — Isolated - Minimal harm Jan 31, 2024 Tag: 0940

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Category: Administration Deficiencies

Corrected: Feb 26, 2024

E — Pattern - Minimal harm Jan 31, 2024 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Feb 26, 2024

D — Isolated - Minimal harm Jan 31, 2024 Tag: 0641

Ensure each resident receives an accurate assessment.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Feb 26, 2024

D — Isolated - Minimal harm Jan 31, 2024 Tag: 0584

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Category: Resident Rights Deficiencies

Corrected: Feb 26, 2024

G — Isolated - Actual harm Jun 12, 2023 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 13, 2023

D — Isolated - Minimal harm Oct 19, 2022 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 20, 2022

D — Isolated - Minimal harm Oct 19, 2022 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 7, 2022

D — Isolated - Minimal harm Oct 19, 2022 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 20, 2022

D — Isolated - Minimal harm Oct 19, 2022 Tag: 0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category: Resident Rights Deficiencies

Corrected: Nov 7, 2022

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 6.6% Yes
Percentage of long-stay residents who lose too much weight Long Stay 4.0% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 1.0% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 1.1% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 0.7% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 99.7% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 100.0% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 0.8% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 7.6% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 17.7% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 98.6% No
Percentage of long-stay residents with pressure ulcers Long Stay 1.7% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 9.0% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 6.0% Yes

Penalty History 2 penalties totaling $30K

Date Type Amount
Jun 24, 2025 Fine $23K
Jun 12, 2023 Fine $7K

Frequently Asked Questions

What is the overall CMS rating for AUTUMN LEAVES NURSING AND REHAB INC?
AUTUMN LEAVES NURSING AND REHAB INC has an overall CMS rating of 3 out of 5 stars. This rating combines health inspection results (3★), staffing levels (1★), and quality measures (5★).
What are the staffing levels at AUTUMN LEAVES NURSING AND REHAB INC?
AUTUMN LEAVES NURSING AND REHAB INC reports 2.99 total nursing hours per resident day (national average: 3.89). RN hours are 0.23 per resident day (national average: 0.68). Nursing staff turnover is 53.6%.
How many beds does AUTUMN LEAVES NURSING AND REHAB INC have?
AUTUMN LEAVES NURSING AND REHAB INC has 125 certified beds with approximately 99 residents. The facility is located at 321 KILGORE DRIVE, HENDERSON, TX 75652.
Does AUTUMN LEAVES NURSING AND REHAB INC have any deficiencies on record?
Yes, AUTUMN LEAVES NURSING AND REHAB INC has 32 deficiencies on record from recent inspections. Of these, 1 are classified as causing actual harm or jeopardy.
Has AUTUMN LEAVES NURSING AND REHAB INC received any fines or penalties?
Yes, AUTUMN LEAVES NURSING AND REHAB INC has received 2 penalties totaling $30K.
Who owns AUTUMN LEAVES NURSING AND REHAB INC?
AUTUMN LEAVES NURSING AND REHAB INC is classified as "Government - Hospital district" ownership. The facility type is "Medicare and Medicaid".
When was AUTUMN LEAVES NURSING AND REHAB INC last inspected?
The most recent health inspection for AUTUMN LEAVES NURSING AND REHAB INC was on Mar 19, 2025. The facility received a health inspection rating of 3 out of 5 stars.
What quality measures are tracked for AUTUMN LEAVES NURSING AND REHAB INC?
AUTUMN LEAVES NURSING AND REHAB INC is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial