Nursing home in Henderson, Texas
Autumn Leaves Nursing and Rehab Inc
Medicare and Medicaid
321 KILGORE DRIVE, Henderson, TX 75652
(903) 657-1923
CMS star ratings
CMS gives this nursing home an overall star rating of 2 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home2
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home2
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home5
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): May 7, 2026. CMS counts 15 health deficiencies in rating cycle 1.
- This nursing home15
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 42 health deficiencies on 10 inspection dates since Sep 30, 2023. By level of harm: 1 immediate jeopardy, 41 potential for harm.
- 1 Immediate jeopardy to resident health or safety
- 0 Actual harm
- 41 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| May 7, 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | F Potential for harm, widespread | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0809 | 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.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and Exploitation Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0688 | 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.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0770 | Provide timely, quality laboratory services/tests to meet the needs of residents.Administration Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
Show the other 32 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| May 7, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| May 7, 2026 | F0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jun 5, 2026 |
| Apr 22, 2026 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Apr 27, 2026 |
| Jan 16, 2026 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 22, 2026 |
| Nov 26, 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Nov 28, 2025 |
| Nov 18, 2025 | F0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Nov 20, 2025 |
| Jun 24, 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Past Non-Compliance Mar 27, 2025 |
| Mar 19, 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0761 | 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.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Environmental Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident Rights Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0693 | 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.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Mar 19, 2025 | F0881 | Implement a program that monitors antibiotic use.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 15, 2025 |
| Sep 17, 2024 | F0573 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Oct 2, 2024 |
| Jun 27, 2024 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jul 12, 2024 |
| Jan 31, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0584 | 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.Resident Rights Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0761 | 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.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members.Administration Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 26, 2024 |
| Jan 31, 2024 | F0942 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident Rights Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Feb 26, 2024 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home2.79 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.23 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home56.8%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 1 penalty for this nursing home: 1 fine totaling $14,901, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 125 |
|---|---|
| Average residents per day | 98.9 |
| Ownership | Government - Hospital district |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | Ml Healthcare (6 facilities) |
| Legal business name | FRIO HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Jun 18, 2004 |
| County | Rusk |
| CMS certification number | 676025 |
Also in Henderson
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| Henderson Health & Rehabilitation Center | 173 | For profit - Limited Liability company |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| UT Health East Texas Henderson Hospital | Acute Care Hospitals | Yes |