The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited June 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
AUTUMN LEAVES NURSING AND REHAB INC
HENDERSON, TX · Medicare-certified · 125 beds
Needs attention
Government-runChain member
3 of 5 overall
3-star nursing home overall, with strong quality measures but a very poor 1-star staffing rating, reported nurse staffing below the federal benchmark (2.98 vs 4.1 hours/resident/day), and $22,925 in fines including a recent federal penalty.
Facility ratings
Health inspections
Staffing
2.9826 hrs/resident/day
Quality measures
Last inspection: January 16, 2026Penalties, last 24 months: $22,925recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.9826.
Staffing detail
- Registered nurses
- 0.21
- Licensed practical nurses
- 0.81
- Nurse aides
- 1.96
- Weekend nursing
- 2.56
Hours per resident per day.
Total staff turnover: 54%
Registered nurse turnover: 33%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
1.9%10%Worsening
Residents with a fall causing major injury
0%0%No change
Residents with pressure ulcers (bedsores)
1.3%2.8%Worsening
Residents with a urinary tract infection
1.4%0%Improving
Residents who lost too much weight
3.1%1.4%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
12.7%8.7%Improving
Residents whose ability to walk got worse
—0%—
Long-stay residents on antianxiety or sleep medication
18.8%13.9%Improving
Short-stay residents newly given an antipsychotic
2%0%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
9.7%3.3%Improving
Residents with depressive symptoms
1.4%0%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—98.6%—
Short-stay residents given the pneumonia vaccine
100%100%No change
What the inspectors found
The home failed to provide safe, appropriate dialysis care for a resident who needed it. Cited November 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 698 — 42 CFR §483.25(l) — S/S: E
The home failed to provide safe and appropriate breathing care when a resident needed it. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 695 — 42 CFR §483.25(i) — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: E
The home failed to properly label and securely store medications and biologicals. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 761 — 42 CFR §483.45(g) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $22,925 was recorded.
Penalties & enforcement
On record with Medicare: 2 fines · $30,368 in total fines.
- $22,925
Federal fine
Jun 24, 2025
- $7,443
Federal fine
Jun 12, 2023
Operator & ownership
- Ownership
- Government - Hospital district
- Chain
- Part of ML HEALTHCARE · 6 homes · 2.7 stars avg
- Occupancy
- 93.9 residents on an average day (75% of 125 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 22 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.