Health inspection·November 26, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accident hazards. CNA A and CNA B failed to lock Resident #1's bed wheels before they raised Resident #1's bed, before they performed peri-care (removal of soiled brief, the cleaning of the genital/ anal areas and placement of a clean brief which required turning Resident #1 side to side in the bed) and pulling Resident #1 up in the bed on 10/23/25. This failure could place residents at risk of significant injury.Findings included: Record review of Resident #1's face sheet, dated 10/23/25, indicated she was 81- years- old female who was re-admitted to the facility on [DATE]. Resident #1 had with diagnoses which included hemiplegia (paralysis) and hemiparesis (weakness) following stroke affecting the right dominant side of the body, generalized muscle weakness, generalized osteoarthritis (cartilage that lines the joints is worn down and bones rub against each other. It causes joint pain, stiffness, swelling and reduced range of motion) dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) aphasia (disorder that can impact speech, as well as the way a person understands both spoken and written language). Record review of Resident #1's MDS, dated [DATE], indicated Resident #1 had no speech, rarely/never made herself understood and rarely/never understood others. Resident #1 had short-term as well as long-term memory problems and had severely impaired cognitive skills for daily decision making. Resident #1 was completely dependent on staff for toileting and required substantial/maximal assistance with eating, oral hygiene, showering, dressing the upper and lower body, putting on/ taking foot wear and personal hygiene. Resident #1 was completely dependent on staff for chair/bed-to-chair transfers and toilet transfers. Resident #1 required substantial/maximal assistance for all other transfers, except sit to stand transfer and walking 10 feet which were not performed due to medical condition or safety concerns. Resident #1 was incontinent of bowel and bladder. Record review of Resident #1's care plan, revised on 8/18/25, indicated Resident #1 was at risk for falls. The care plan interventions included follow facility fall protocol. During an observation on 10/23/25 at 11:35 AM, CNA A and CNA B provided Resident #1 with incontinent care and repositioned her in bed. CNA A and CNA B unlocked the bed wheels and moved Resident #1's right side away from the wall. CNA B stood on the right side of the bed and CNA A stood on the left side of the bed. CNA B and CNA A raised Resident #1's bed and performed incontinent care, turning Resident #1 to the right and left of the bed while the wheels of the bed were not locked. CNA B and CNA A then lifted (using the draw sheet) Resident #1 higher in the bed. The wheels remained unlocked and the bed moved gently as they (CNA A and CNA B) moved Resident #1. During an interview on 10/23/25 at 11:50 AM, CNA B was asked if she should have done anything differently during incontinent care and repositioning of Resident #1. CNA (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676025 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 11/26/2025 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)