Health inspection·November 18, 2025

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some are in place causing further damage to patient's access. SNF has been notified countless times. Skin tears and signs of erosion present on access. Record review of Resident #1's dialysis center patient note, dated 8/16/25 at 11:10 a.m., by PCT G, indicated .Patient's bandages from previous treatment were not removed by the staff at her nursing facility. They were covered with an additional dressing but not removed. They have been told to remove them before the patient goes to bed in the past but continue not to do so. A note has been sent with the Dialysis Communication Record and the charge nurse was notified. Access extremity remains swollen and patient reports pain in access and pressure dressings remain in place causing further damage to patient's access. Record review of Resident #1's dialysis center patient note, dated 8/19/25 at 11:43 a.m by PCT G, indicated .When patient arrived to treatment today the patient's bandages from previous treatment were still present and not removed by the staff at her nursing facility. The facility has been told to remove them before the patient goes to bed in the past but continues not to do so. A note has been sent with the Dialysis Communication Record and the charge nurse was notified. During an interview on 10/13/25 at 9:50 a.m., the ADM said it was the responsibility of the charge nurse on the unit to provide care related to the dialysis access ports. The ADM said the charge nurse was expected to complete a checklist form prior to the resident leaving for dialysis and again upon returning which required assessing the dialysis port. During an interview on 10/13/25 at 9:55 a.m., the ADON said it was the unit nurse's responsibility for conducting daily assessments of the dialysis ports and to prepare a resident for transport to dialysis. The ADON said the unit nurse was expected to complete a computerized resident assessment and fill out a physical assessment sheet that the resident took to dialysis with them. The ADON said when a resident returned from dialysis it was the unit nurse's responsibility to look at the dialysis assessment sheet for any information/education sent back from the dialysis center and complete another assessment of the resident's access port. During an interview on 10/13/25 at 11:00 a.m., LVN B said the procedure for getting a resident ready for dialysis included assessing the port for function and signs of infection, filling out a computer-based assessment, and filling out a dialysis transfer form which went with the resident. The LVN said when a resident returned from dialysis the dressing should be removed to inspect the port. LVN B said she did not know Resident #1 and no residents on her assigned hallway received dialysis treatments.During an interview on 10/13/25 at 11:10 a.m., LVN C said the charge nurse was responsible for assessing the resident dialysis access port, checking for medication orders, and filling out a dialysis transfer form. LVN C said when a resident returned from dialysis the dressing should be removed and the port left open to the air. LVN C said she did not know Resident #1 and no residents on her assigned hallway received dialysis treatments. During an interview on 10/13/25 at 11:15 a.m., LVN D said she knew Resident #1 and performed her weekly skin assessments to monitor for any signs of infection around the dialysis access port. LVN D said she did not recall seeing a dressing in place which covered the port when conducting skin assessments on Resident #1. LVN D said it was the unit nurse's responsibility to assess the resident's dialysis access ports before and after dialysis treatments. During an interview on 10/13/25 at 11:35 a.m., LVN E said the charge nurse was expected to complete a dialysis port site assessment on residents before they went to dialysis. LVN E said the inspection included assessing the port for function, checking blood pressure, and vital signs. LVN E said she was unsure if a dialysis port site should be covered by a dressing or not. LVN E said she did not know Resident #1 and no residents on her assigned hallway received dialysis treatments. During an interview on 10/13/25 at 12:00 p.m., RN A said she worked at the dialysis center where Resident #1 received treatments. RN A said she provided education to the facility multiple times regarding removing the dialysis dressing within 2-4 hours after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676025 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete dialysis. RN A said she told the facility staff that leaving the dressings on the access site could cause clotting problems. RN A said she noted multiple occurrences of the same dressing that was applied at the dialysis center still in place when Resident #1 returned for her next appointment. Attempted telephone interviews with Resident #1 on 10/13/25 at 10:30 a.m. and 1:45 p.m., the telephone number indicated the number was disconnected or no longer in service. During an interview on 10/13/25 at 3:35 p.m., the RP said she frequently visited Resident #1 in the facility. The RP said she usually noticed a dressing in place on the resident's access port, she said the facility began removing the dressing when the resident started having increased swelling in her arm. The RP said Resident #1 discharged home with home health and her phone was broken. Record review of the facility's, undated, policy titled Hemodialysis - Care of Resident, indicated .Provide routine AV Shunt (a medical device created by surgically connecting an artery to a vein) Care and Monitoring per physician orders. Event ID: Facility ID: 676025 If continuation sheet Page 3 of 3