C75

AUTUMN LEAVES NURSING AND REHAB INC

Grade C 75/100 composite score

Government - Hospital district

CMS Star Ratings

Overall
3/5
Health Insp.
3/5
Quality
5/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

125

Ownership

Government - Hospital district

Total Fines

$30,368

Last Survey

N/A

321 KILGORE DRIVE, HENDERSON, TX 75652
9036571923

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.22h
LPN
0.78h
CNA
1.86h
Total
2.86h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

FRIO HOSPITAL DISTRICT

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2022

100%

ML-HENDERSON LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Dec 2022

LANGSDALE, TROY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2022

MILLER, LAURA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2022

VOZZA, BRENDA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2022

RUFF, MICHAEL

IndividualCORPORATE OFFICERSince Dec 2022

ML REAL ESTATE-HENDERSON, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince Dec 2022

LANGSDALE, TROY

Individual5% OR GREATER MORTGAGE INTERESTSince Dec 2022

MILLER, LAURA

Individual5% OR GREATER MORTGAGE INTERESTSince Dec 2022

Penalties & Fines (2)

$30,368total fines
DateTypeDescriptionAmount
Jun 24, 2025Fine$22,925
Jun 12, 2023Fine$7,443

Health Inspection Deficiencies (32)

November 26, 2025Health1 deficiency
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

November 18, 2025Health1 deficiency
0698EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Nov 20, 2025
March 19, 2025Health13 deficiencies
0561DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Apr 15, 2025
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 15, 2025
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Apr 15, 2025
0690DMinimal harm, Isolated

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

Corrected Apr 15, 2025
0693DMinimal harm, Isolated

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

Corrected Apr 15, 2025
0695EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Apr 15, 2025
0755EMinimal harm, Pattern

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

Pharmacy Service Deficiencies

Corrected Apr 15, 2025
0757DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Apr 15, 2025
0761EMinimal harm, Pattern

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

Corrected Apr 15, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 15, 2025
0881DMinimal harm, Isolated

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Apr 15, 2025
0558EMinimal harm, Pattern

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Apr 15, 2025
0921EMinimal harm, Pattern

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

Environmental Deficiencies

Corrected Apr 15, 2025
September 17, 2024Health1 deficiency
0573DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Oct 2, 2024
June 27, 2024Health1 deficiency
0695EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Jul 12, 2024
January 31, 2024Health10 deficiencies
0584DMinimal harm, Isolated

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

Corrected Feb 26, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 26, 2024
0656EMinimal harm, Pattern

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

Corrected Feb 26, 2024
0940DMinimal harm, Isolated

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

Administration Deficiencies

Corrected Feb 26, 2024
0942DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Feb 26, 2024
0550DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Feb 26, 2024
0677DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Feb 26, 2024
0695EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Feb 26, 2024
0761DMinimal harm, Isolated

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

Corrected Feb 26, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 26, 2024
June 12, 2023Health1 deficiency1 severe
0689GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Jun 13, 2023
October 19, 2022Health4 deficiencies
0550DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Nov 7, 2022
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Oct 20, 2022
0690DMinimal harm, Isolated

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

Corrected Nov 7, 2022
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Oct 20, 2022

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Frequently Asked Questions

What is the CareGrader rating for AUTUMN LEAVES NURSING AND REHAB INC?

AUTUMN LEAVES NURSING AND REHAB INC in HENDERSON, Texas has a CareGrader grade of C (Average), with a composite score of 75 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for AUTUMN LEAVES NURSING AND REHAB INC?

AUTUMN LEAVES NURSING AND REHAB INC has an overall CMS star rating of 3 out of 5, a health inspection rating of 3/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does AUTUMN LEAVES NURSING AND REHAB INC have?

AUTUMN LEAVES NURSING AND REHAB INC has 32 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has AUTUMN LEAVES NURSING AND REHAB INC been fined?

Yes. AUTUMN LEAVES NURSING AND REHAB INC has $30,368 in total fines from CMS enforcement actions across 2 penalties.

How many beds does AUTUMN LEAVES NURSING AND REHAB INC have?

AUTUMN LEAVES NURSING AND REHAB INC has 125 certified beds with approximately 98 current residents (78% occupancy). The facility is located at 321 KILGORE DRIVE, HENDERSON, Texas 75652. It is a government - hospital district facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.