Community Care Center of Hondo

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility or the resident through a means other than a postal service for 2 of 8 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for ten of ten residents (Residents #4, #15, #19, #25, #27, #29, #33, #34, #36 and #37) reviewed for food and nutrition services. The facility failed to ensure the glazed lemon cake served for the lunch meal on 09/09/2025 was pureed to the correct consistency as required for Residents #4, #15, #19, #25, #27, #29, #33, #34, #36 and #37 who were ordered a pureed diet. This deficient practice could place residents at risk of choking, poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure bedrooms measured at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms for 4 of 35 multiple occupancy resident rooms (#A5, #A6, #A9, and #A11) reviewed for physical environment. The facility failed to ensure rooms #A5, #A6, #A9, and #A11, which were multiple occupancy resident rooms, provided a minimum of 80 square feet per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with dignity and respect in a manner and environment that enhances his and her quality of life for 1 (Resident #2) of 8 residents reviewed, in that: CNA C referred to Resident #2's brief during catheter care as a diaper. The facility failed to ensure RN B provided privacy to Resident #1 when performing tracheostomy care (a surgical opening made through the front of the neck into the windpipe used to help a person breathe when the normal route through the mouth, nose, or throat is blocked or impaired). This deficient practice could affect residents at the facility who receive assistance with care and could place them at-risk for diminished quality of life, loss of dignity, and low self-esteem.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive) for 1 (Resident #4) of 8 residents reviewed for right to formulate advance directive. 1. The facility failed to ensure Resident #4's OOH DNR was incomplete and not able to be used in emergency situations. This failure could affect any residents who have medical records and could result in misinformation about professional care provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 13 residents (Residents #1 and #19) reviewed for accuracy.1. The facility failed to ensure Resident #1's quarterly MDS assessment, dated 6/25/25 accurately reflected the resident's use of insulin.2. The facility failed to accurately document Resident #19's dental status on the resident's annual assessment dated [DATE]. These failures could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 residents (Resident #1) reviewed for oxygen therapy:Resident #1's oxygen concentrator filter was covered in a thick white/gray substance. This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (A wing medication cart) and 1 of 2 medication (B wing) storage rooms reviewed for medication storage. 1. The facility failed to ensure Resident #1's metolazone (diuretic that treats fluid retention) had a change direction sticker placed on the package. 2. The facility failed to ensure the B wing emergency cart did not contain expired supplies. These deficient practice could place residents at risk of medication misuse and diversion.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevent and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 4 residents (Resident #21 and Resident #41) reviewed for infection control. The facility failed to ensure RN B wore gloves when picking up Resident #21's urostomy tube (surgical procedure that creates an opening, stoma, in the abdominal wall to divert urine away from the bladder and drains into a collection bag) off the floor. The facility failed to ensure RN B wore proper PPE while providing wound care to Resident #41. These deficient practices could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observations, interviews and record review failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped on 11/3/2024 out of facility and was across a 35 per mile street, at store near gas pumps, near a highway, that was 40 miles per hour. On 11/2/2024 Resident #1 attempted to elope, before a nurse stopped Resident #1 from going outside. An IJ was identified on 4/25/2025. The IJ template was provided to the facility on 4/25/2025 at 6:41 PM. While the IJ was removed on 4/26/2025 at 7:53 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. -Container of Thick-it had a scoop stored inside container -Two 5-gallon clear food storage containers with dry cereal did not have a label and was not dated. These failures could place residents at risk of food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to be treated with respect and dignity for 1 (Resident #53) of 25 residents reviewed, in that: Resident #25 was referred to as a feeder within her clinical record. This deficient practice could cause psychosocial harm due to feelings of embarrassment and loss of dignity.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that 4 of 35 multiple occupancy resident rooms (#A5, #A6, #A9, and #A11) provided a minimum of 80 square (sq.) feet (ft.) per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests for 5 of 6 residents (Resident #1, #2, #3, #5, and #6), in that: 1. The facility failed ensure Resident #1's room was free from flies. Resident #1 was hospitalized on [DATE] for maggot infestation around the tracheostomy and acute on chronic respiratory failure. Resident #1's stoma was suctioned around the trach until it was cleared of all maggots. A bronchoscopy was performed and cleared clots. Resident #1 was admitted to ICU for continued mechanical ventilation. 2. Resident #3, and Resident #5 had a flies in their room as they ate their breakfast and lunch tray on 11/10/2023. 3. Resident #6 had a fly on his shirt while he was eating his noon meal in the dining room on 11/11/2023. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for neglect, in that: The facility failed to prevent Resident #1 from having maggots in his tracheostomy site, who was hospitalized on [DATE] for maggot infestation around the tracheostomy and acute on chronic respiratory failure. Resident #1's stoma was suctioned around the trach until it was cleared of all maggots. A bronchoscopy was performed and cleared clots. Resident #1 was admitted to ICU for continued mechanical ventilation. An IJ was identified on 11/12/2023. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 1 of 28 rooms and 1 and 1 kitchen reviewed for pests, in that: The facility failed to ensure the pest control program was effective in all areas of the facility. 1. Freezer 2 had one, live, three-centimeter roach and one, live, one-centimeter ant crawling inside the lower compartment. 2. Fridge 3 had two, live, one-centimeter ants crawling inside the lower compartment of the unit. 3. Fridge 2 had two, unmoving, one-centimeter ants inside the lower compartment of the unit. 4. room [ROOM NUMBER] had a live four-inch roach crawling along the wall. This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 2 of 24 residents (Resident #36) reviewed for resident rights, in that: Residents #36 and #148 were told they could not flush toilet paper down the toilet of their shared bathroom and must dispose of soiled toilet paper in the receptacle. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on interview and record review; it was determined the facility failed to ensure residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 6 (Resident #31) residents reviewed for resident rights. The facility failed to ensure Resident #31 had the right to receive visitors inside the facility. This failure placed residents at risk of isolation, decreased emotional well being and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #44) reviewed for pharmacy services in that: The facility failed to accurately transcribe and clarify Resident #44's prescription for levofloxacin (an antibiotic) into the electronic medication administration record. This deficient practice could affect residents who received medications and place them at risk for adverse reaction and/or a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #98) reviewed for unnecessary medications in that: The facility failed to address the pharmacist consultant's recommendation for the routine use of antibiotic therapy for Resident #98. This failure could place residents at risk for adverse drug reactions and receiving unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #34) reviewed for infection control practices, in that: CNA C and CNA D did not utilize appropriate hand hygiene during incontinent/catheter care to Resident #34. These failures could place residents who required incontinent/catheter care at risk for infection or a decline in health.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that 4 of 35 multiple occupancy resident rooms (#A5, #A6, #A9, and #A11) provided a minimum of 80 square (sq.) feet (ft.) per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms.