Autumn Leaves Nursing and Rehab INC
321 Kilgore Drive, Henderson, TX 75652 · Rusk County · 125 certified beds · avg 99 residents/day · certified since Jun 18, 2004
Part of chain: ML HEALTHCARE (6 facilities, chain avg rating 2.3★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$14,901
Fines, last 3 years
2.62
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 24, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 27, 2025 (Past Non-Compliance)
All citations in the current public record (42)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 7, 2026 | F · Potential for harm, facility-wide | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Apr 22, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jan 16, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Nov 26, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 18, 2025 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Jun 24, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 19, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 19, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Sep 17, 2024 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Jun 27, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jan 31, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 31, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jan 31, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. |
| Jan 31, 2024 | D · Potential for harm, one-off | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (13 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 12 | 0 | E |
| 2025 | 16 | 1 | J ▲ |
| 2026 | 14 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $14,901.
| Date | Type | Amount / length |
|---|---|---|
| Jun 24, 2025 | Fine | $14,901 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.62 | 3.46 | 3.95 | bottom 5% in Texas; bottom 5% in the U.S. |
| Registered Nurse hours | 0.22 | 0.44 | 0.69 | bottom 11% in Texas; bottom 3% in the U.S. |
| Weekend total nurse staffing | 2.29 | 3.04 | 3.50 | bottom 7% in Texas; bottom 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.17 | 0.34 | 0.48 | bottom 12% in Texas; bottom 7% in the U.S. |
| Total nursing staff turnover (%) | 56.8 | 55.3 | 45.8 | bottom 40% in Texas; bottom 22% in the U.S. |
| RN turnover (%) | 20.0 | 54.6 | 42.9 | top 6% in Texas; top 13% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.79, RN 0.23, weekend 2.44. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Frio Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/01/2022 |
| Langsdale, Troy | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/01/2022 |
| Langsdale, Troy | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2022 |
| Langsdale, Troy | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2022 |
| Miller, Laura | Individual | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/01/2022 |
| Miller, Laura | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2022 |
| Miller, Laura | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2022 |
| ML Real Estate-Henderson, LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/01/2022 |
| ML Real Estate-Henderson, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2022 |
| Ml-Henderson LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2022 |
| Ml-Henderson LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/27/2025 |
| Ruff, Michael | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2022 |
| Turner, Victor | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2022 |
| Vozza, Brenda | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2022 |
| Vozza, Brenda | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "What happens if a resident is hungry between meals or misses a mealtime — what food options are available?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Henderson Health & Rehabilitation Center | 2.0 mi | Henderson, TX | ★★☆☆☆ | 2/5 | abuse |
| Avir at Overton | 12.8 mi | Overton, TX | ★★☆☆☆ | 1/5 | abuseSFF |
| Arbor Grace Guest Care Center | 14.0 mi | Kilgore, TX | ★☆☆☆☆ | 2/5 | |
| Willow Rehab & Nursing | 14.3 mi | Kilgore, TX | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676025.