Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Community Care Center Of Hondo during CMS and state inspections, most recent first.
Delayed Resident Mail Delivery: Two residents reported they did not receive mail on Saturdays because the Front Office was closed and Saturday mail was locked in the BOM's office until Monday. The BOM stated she collected and sorted resident mail, and the Activities Director confirmed mail delivery to residents occurred Monday through Friday only, with Saturday mail held until the next business day. The Administrator stated he was not aware residents were missing Saturday mail delivery.
Failure to Maintain Resident Dignity During Care: A CNA referred to a resident's brief as a "diaper" during catheter/incontinent care while the resident was sleepy and had moderately impaired cognition. In a separate event, an RN performed tracheostomy care for a cognitively intact resident with the bedroom door open while people were walking in the hallway, and the RN acknowledged the lack of privacy.
Incomplete OOH DNR Documentation: A resident with severely impaired cognition and a documented DNR order had inconsistent advance directive paperwork in the chart. One OOH DNR lacked a physician signature and had an incomplete notary section, while a second copy had witness signatures with illegible dates and was not uploaded into the record. Staff interviews showed confusion about how DNR paperwork was completed and validated, and the resident's family member stated they signed the form with a local notary in another state and had not been at the facility for months.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised, crossing a street and reaching a nearby store. Despite documented behaviors indicating elopement risk, the resident's risk assessment was scored as zero, and no additional supervision or safety interventions were implemented. Communication lapses among staff and failure to follow the facility's elopement policy contributed to the incident.
The facility's kitchen failed to meet professional standards for food storage and labeling. A container of Thick-it was found with a scoop inside, and two large containers of dry cereal were unlabeled and undated. The Dietary Manager admitted the oversight and acknowledged the risk of foodborne illness due to improper labeling and storage practices.
A resident with severe cognitive impairment was inappropriately referred to as a 'feeder' in their clinical record, contrary to the facility's dignity policy. The resident required assistance with eating due to dementia and was spoon-fed by staff. The interim DON acknowledged the term's use was unacceptable and not aligned with facility expectations.
The facility failed to provide the required minimum space of 80 square feet per resident in four multiple occupancy rooms. Rooms designated for three residents were found to be below the required space per resident, with measurements ranging from 72.3 to 76.0 square feet per resident. The Administrator confirmed the deficiency and sought to continue room waivers.
Delayed Resident Mail Delivery
Penalty
Summary
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 for 2 of 8 residents reviewed for resident rights. During a confidential resident group meeting, 2 residents stated they did not receive mail on Saturdays because the Front Office Staff did not work on Saturdays. They reported that because the front office was locked, mail delivered on Saturday was held there and not delivered until the following Monday. One resident stated it bothered them that mail was delayed, especially when expecting items from a family member who lived out of town. During interviews, the BOM stated she collected mail from the outside box, sorted resident mail, and placed personal mail in a Resident Mail box in her office. The Activities Director stated she retrieved mail from that box and delivered it to residents with the help of a resident, but mail delivery occurred Monday through Friday only. The BOM stated that on most Saturdays she would collect the mail and place it in her office, where it remained locked until Monday because the business office was closed. The Activities Director confirmed Saturday mail was not delivered to residents and was instead picked up on Monday. The Administrator stated he was not aware residents were not receiving Saturday mail delivery and believed the facility had a good system in place for delivering mail.
Failure to Maintain Resident Dignity During Personal and Tracheostomy Care
Penalty
Summary
The facility failed to treat a resident with dignity and respect when CNA C referred to the resident's brief as a "diaper" during catheter and incontinent care. Resident #2 had an indwelling catheter, was always incontinent of bowel, and had a BIMS score of 10 out of 15, indicating moderately impaired cognition. During observation, CNA C assisted with catheter care and incontinent care while the resident was falling asleep, helped place a clean brief on the resident, attempted to wake the resident, and stated, "we are going to put on your diaper now." CNA C later stated she used the word diaper instead of brief and acknowledged she had been trained on the proper words but sometimes forgot when in a hurry. The facility also failed to provide privacy during tracheostomy care for another resident. Resident #1 was cognitively intact and required oxygen and tracheostomy care, with orders for daily inner cannula changes and a care plan directing tracheostomy care every shift and privacy and dignity during all procedures. During observation, RN B performed tracheostomy care with the bedroom door left open while the resident's bed was positioned nearest the door and residents and staff were seen walking in the hallway. RN B stated she was nervous during the procedure and forgot to close the door, and acknowledged that leaving the door open was not dignified and that the door should have been closed to provide privacy. The resident stated that nursing usually closed the bedroom door during tracheostomy care to provide privacy and said it did not bother him that the door was open on this occasion. The DON stated it was the expectation that staff provide privacy during care because it was the resident's right to dignity.
Incomplete OOH DNR Documentation
Penalty
Summary
The facility failed to ensure that Resident #4 had a complete and valid out-of-hospital DNR order available for use in emergency situations. Resident #4 was admitted and readmitted with diagnoses including hypo-osmolality, hyponatremia, type 2 diabetes mellitus, muscle wasting and atrophy, muscle weakness, and multiple wedge compression fractures of the thoracic and lumbar spine. The admission record identified the resident's advance directive as DNR, and the MDS assessment indicated the resident had severely impaired cognition for daily decision making. Record review showed the care plan identified the resident and/or responsible party's advance directive choice as DNR status and out-of-hospital DNR, with interventions for social services to review advance directives and make changes as requested. The order summary also showed a DNR order with no end date. However, the first OOH DNR in the record was signed by the resident's family member and an out-of-state notary, but it did not contain a physician's signature and the notary section was incomplete. A second OOH DNR was also present and contained the family member's signature, two witness signatures, and a physician's signature, but the witness signature dates were written over and not legible. During interviews, the DON stated all residents' DNRs were in the EMR and that medical records helped complete OOH DNRs and checked validity before uploading them. The MDS coordinator stated the facility had no social worker during her time there and that DNR paperwork was handled collaboratively by the DON and BOM. CNA C/Medical Records stated she had no formal training on completing DNR paperwork and did not think a physician's signature was required. The DON later stated she noticed the missing physician signature and had the DNR signed by a physician, but the second copy had not been uploaded into the resident's record. The resident's family member stated they had signed the paperwork at a local notary in another state and had not been at the facility since February 2025, while [NAME] D stated he had witnessed the family member sign the OOH DNR at the facility.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with dementia, who was admitted for hospice respite care and was severely cognitively impaired, was able to elope from the facility. The resident was independently ambulatory, had a history of wandering, and required supervision, as documented in multiple progress notes and care plans. Despite these documented risks, the resident's elopement risk assessment was scored as zero, indicating no risk, even though the assessment noted wandering behaviors. The facility did not have a wander guard system, and the front doors were not locked. On one occasion, the resident attempted to elope but was stopped by a nurse. The following day, the resident successfully exited the facility by leaving with a church group and was later found at a nearby store across a two-lane street and near a four-lane highway. Staff interviews revealed that the resident was missing for approximately 10-20 minutes before being located and returned to the facility. Documentation and staff statements confirmed that the resident was not properly identified as an elopement risk, and interventions such as increased supervision or physical barriers were not implemented prior to the incident. Interviews with staff and review of records indicated lapses in communication and assessment. The night nurse was not informed of the resident's wandering behaviors by the previous shift, and the Assistant Director of Nursing was unaware of the resident's elopement attempt until after the successful elopement. The facility's elopement policy required identification and care planning for residents at risk, but these procedures were not followed, resulting in the resident's unsupervised exit from the facility.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service in its kitchen, as observed during a survey. A container labeled Thick-it was found with a scoop stored inside, which is against the facility's policy and could lead to cross-contamination or foodborne illness. Additionally, two 5-gallon clear food storage containers filled with dry cereal were observed to be unlabeled and undated, contrary to the facility's policy that requires dry foods to be labeled and dated when removed from their original packaging. The Dietary Manager acknowledged during an interview that the containers with dry cereal were filled that day and were not labeled due to oversight. The manager confirmed that it is the responsibility of all staff to label foods when opened and that failing to do so increases the risk of foodborne illness. The manager also stated that storing scoops inside food containers is not common practice and could lead to cross-contamination. The facility's policy and the U.S. FDA Food Code were reviewed, highlighting the requirement for proper labeling and storage of in-use utensils to prevent contamination.
Resident Referred to as 'Feeder' in Clinical Record
Penalty
Summary
The facility failed to ensure the resident's right to be treated with respect and dignity, as evidenced by the use of inappropriate terminology in the clinical record of a resident. The resident, who was admitted with diagnoses including altered mental status, dysphagia oral phase, and unspecified dementia, was referred to as a 'feeder' in a progress note. This terminology was used in the context of discussing the resident's need for assistance with eating due to severe cognitive impairment, as indicated by a BIMS score of 04. The resident required assistance with activities of daily living, including eating, and was spoon-fed by staff. The facility's policy on Quality of Life - Dignity, revised in August 2009, emphasizes that residents should be treated with dignity and respect at all times, including being addressed by their name of choice and not labeled by their care needs. During an interview, the interim DON acknowledged that the use of the term 'feeder' was unacceptable and not in line with the facility's expectations. The nurse who wrote the progress note was not a full-time staff member and was not present during the survey period.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that four of its multiple occupancy resident rooms provided the minimum required space of 80 square feet per resident. Specifically, rooms designated for three residents were found to be below the required space per resident. Room #A5 measured 217 square feet, equating to 72.3 square feet per resident, with one resident residing in the room. Room #A6 measured 220.5 square feet, equating to 73.6 square feet per resident, with no residents residing in the room. Room #A9 measured 228 square feet, equating to 76.0 square feet per resident, with two residents residing in the room. Room #A11 measured 225 square feet, equating to 75.0 square feet per resident, with one resident residing in the room. Additionally, room #A11 was observed to have two light fixtures and two call light systems visible. The Administrator confirmed that these four rooms were below the required 80 square feet per resident and expressed a desire to continue the room waivers for these rooms. A review of the Bed Classification Form indicated that these rooms were certified for three residents per room.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hondo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medina Valley Health & Rehabilitation Center | 18.7 mi | ★★★★★ | 11 | 0 |
| Devine Health & Rehabilitation | 19 mi | ★★★★★ | 6 | 0 |
| Lytle Nursing Home | 20.1 mi | ★★★★★ | 0 | 0 |
| Avir At Bandera | 25.1 mi | ★★★★★ | 12 | 0 |
| Cedar Creek Nursing And Rehabilitation Center | 26 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.