C-
58/100AUTUMN LEAVES NURSING AND REHAB INC Inspection Report, Violations & Safety Grade (HENDERSON, Texas)
321 KILGORE DRIVE, HENDERSON, Texas 75652
Phone: 9036571923
CMS Overall:2/5
Overview & Bed Count
Certified Beds
125
Avg Residents/Day
106.7
Ownership
Government - Hospital district
Provider Type
Medicare and Medicaid
County
Rusk
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing1/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.26 | 0.44 | -0.18 |
| Total Nurse Hours per Resident per Day | 2.63 | 3.42 | -0.78 |
| CMS Staffing Rating | 1/5 | 1.9/5 | - |
| Nursing Staff Turnover | 56.5% | 50.8% | - |
Health Citation History
42 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-05-07 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | F – Moderate Harm Potential |
| 2026-05-07 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2026-05-07 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2026-05-07 | Nutrition and Dietary Deficiencies | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | E – Moderate Harm Potential |
| 2026-05-07 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-05-07 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2026-05-07 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2026-05-07 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2026-05-07 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-05-07 | Administration Deficiencies | Provide timely, quality laboratory services/tests to meet the needs of residents. | D – Moderate Harm Potential |
| 2026-05-07 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-05-07 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | D – Moderate Harm Potential |
| 2026-04-22 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-01-16 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-11-26 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-11-18 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E – Moderate Harm Potential |
| 2025-06-24 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-03-19 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | E – Moderate Harm Potential |
| 2025-03-19 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2025-03-19 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2025-03-19 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-03-19 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E – Moderate Harm Potential |
| 2025-03-19 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2025-03-19 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2025-03-19 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-03-19 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2025-03-19 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-03-19 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2025-03-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-03-19 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | D – Moderate Harm Potential |
| 2024-09-17 | Resident Rights Deficiencies | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | D – Moderate Harm Potential |
| 2024-06-27 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2024-01-31 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2024-01-31 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2024-01-31 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-01-31 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-01-31 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-01-31 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-01-31 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-01-31 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-01-31 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | D – Moderate Harm Potential |
| 2024-01-31 | Resident Rights Deficiencies | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | D – Moderate Harm Potential |
Fire Safety Citation History
8 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-05-07 | Smoke Deficiencies | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | E – Moderate Harm Potential |
| 2026-05-07 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2026-05-07 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2026-05-07 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2025-03-19 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | F – Moderate Harm Potential |
| 2025-03-19 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-03-19 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2025-03-19 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
Total Penalties & Fines
$14,901
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-06-24 | Fine | $14,901 | - |
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Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the HENDERSON area at no cost.
Find Safe, Vetted Facilities Near HENDERSON
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.