Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Del Rio Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident council grievances were not fully followed up on or resolved, including repeated complaints about late meals, coffee timing, food quality, dirty utensils, missing items, and cold dinners. Residents reported ongoing dietary problems after staff turnover, while staff interviews showed unclear responsibility for grievance follow-up and inconsistent resolution of group concerns. Facility policy required the community to consider resident and family group views and communicate decisions regarding their proposals.
The facility failed to ensure its activities program was directed by a qualified professional after the Activity Director left for another department and the position remained vacant. An unlicensed/uncertified former Activity Director with a lapsed certification was providing part-time group activities while the ADMIN confirmed no certified Activity Director was on staff and the facility was recruiting.
A facility failed to provide drinks, including coffee and water, to residents seated in Dining Room A and Dining Room B while waiting for late meal trays. Observations showed multiple residents at both breakfast and lunch services sitting without drinks, and when residents asked for coffee or a snack, staff said there were no drinks yet or that drinks would come on the tray. Interviews with CNA, Resident Council, DS, and DCS confirmed meals were running behind and residents were not receiving drinks while waiting.
Late Meal Service and Delayed Tray Delivery: Residents in two dining rooms were seated for breakfast and lunch while trays and drinks were not yet available, with meal carts and trays arriving 15 to 45 minutes late on multiple occasions. Staff, the resident council, and cognitively intact residents reported that meals were often late, and the ADMIN and DS acknowledged staffing changes and the absence of a Dietary Supervisor contributed to ongoing meal service delays.
Kitchen Food Storage, Labeling, and Thawing Deficiencies: The facility failed to keep food properly labeled, dated, sealed, and stored, with unlabeled or undated milk, dessert, onion, ground meat, soup, freezer items, fruit, and spaghetti sauce observed in the kitchen and pantry. The kitchen also had poor sanitation with debris and flies present, and an LPN/cook was observed thawing frozen chicken in a sink under hot running water for meal service, which he acknowledged was not the appropriate method.
A resident with a colostomy, hemiplegia, and hemiparesis received ostomy care with the door open and privacy curtain not drawn while others passed by the room. In a dining room, a CNA was observed using a personal cell phone during feeding assistance to a resident. Staff interviews confirmed that privacy should be maintained during personal care and that personal phone use is not appropriate while providing resident care.
Quarterly MDS assessment was not completed within the required 3-month timeframe for a resident with DM2, dysphagia, and bilateral carotid artery stenosis. The RNAC said there was no RN available to sign the MDS because the DON had resigned, and the assessment remained overdue in the EHR despite the facility policy requiring quarterly updates per the RAI manual.
A resident with CVA, hemiplegia, hemiparesis, cognitive impairment, and a colostomy did not have a comprehensive person-centered care plan with measurable goals and timeframes. Her baseline plan listed several care needs, but it did not include individualized activities for paralysis or fully reflect her activity preferences, despite an activity assessment showing she enjoyed groups, fresh air, religious services, and morning activities. Staff interviews also showed uncertainty about whether in-room activities were being provided to the bedbound resident.
Care Plan Not Updated for Foley Catheter: A resident with neuromuscular dysfunction of the bladder had an indwelling Foley catheter documented on the MDS and in physician orders, but the care plan did not include catheter interventions. The RNAC acknowledged the omission was an oversight, and the ADNS confirmed the care plan had not been updated to reflect the resident’s Foley catheter needs.
Failure to Provide Individualized Activity Programming: Two residents with CVA-related paralysis and severe cognitive impairment did not have documented Section F activity preferences or care plans reflecting individualized activities for paralysis. One resident’s assessment showed preferences for fresh air, religious services, and activities throughout the day, but June activity records were inaccurate and the resident was observed in bed watching TV. Staff reported the AD position was vacant after the former AD moved to dietary, and they could not confirm that in-room activities were being provided to bedbound residents.
Improper incontinent and catheter care during peri-care. A resident with an indwelling catheter and bowel incontinence was observed receiving care in which a CNA removed the soiled brief but left the draw sheet in place, cleaned the resident, and then turned the resident back onto the same soiled draw sheet before applying a clean brief. The CNA stated the proper process was to remove the soiled draw sheet and apply a clean brief before turning the resident back, and the ADNS stated the expectation was to apply a clean brief after cleaning to prevent cross-contamination and potential infection.
The facility failed to employ sufficient dietary staff with the needed competencies and skills, including a qualified dietician, and the kitchen was observed unclean, disorganized, and behind on tasks with staff unsure of what to do. An interview showed the new DS had just taken over from the prior DS, had not previously worked in the kitchen, and had only recently completed a food manager course, while the facility policy required a qualified dietician or an experienced/qualified food service director with the proper training.
Hand Hygiene Not Performed During Meal Tray Pass: CNA B passed meal trays to 8 residents on B hall without washing or sanitizing hands before starting or between residents. CNA B stated hand hygiene between residents and tasks could put residents at risk for infection, while the ADMIN stated staff are expected to follow policy. The facility policy states hand hygiene is the primary means to prevent the spread of infections and is required before and after direct resident contact and food handling.
Two residents admitted under the custody of the U.S. Marshals Service were kept in shackles at the wrists, ankles, and abdomen, under constant armed guard, without medical justification or physician orders for restraints. Nursing staff monitored skin integrity but did not have authority over restraint use, which was dictated by law enforcement. The facility's restraint policy, which requires restraints only for medical symptoms, was not followed in these cases.
A resident with severe cognitive impairment was given an antipsychotic medication without proper informed consent, as the signed consent form lacked information about the medication's risks and benefits. The resident's representative was unaware of potential side effects and the method of administration, and facility staff confirmed the required information was not provided prior to medication administration.
Two residents admitted under the custody of the U.S. Marshal Service were continuously shackled at the wrists, ankles, and abdomen, and supervised by armed guards, without physician orders or consents for the restraints. Facility records and staff interviews confirmed that the restraints were not based on medical necessity, and the facility's restraint management policy requiring a restraint-free environment and proper documentation was not followed.
A resident was discharged without the required MDS discharge assessment being completed or transmitted to CMS, due to human error by the MDS Nurse who missed the process when the resident left sooner than expected. The facility's policy requires timely completion and transmission of such assessments, but this was not followed.
A resident with a physician's order for blood pressure medication requiring pre-administration BP checks did not have blood pressure results documented in the electronic medical record prior to medication administration. The CMA was aware of the order's parameters but did not record the BP readings, citing a lack of a designated area in the system and did not report this issue. Other staff confirmed this documentation lapse, which was not in accordance with facility policy.
The facility failed to maintain the cleanliness of the ice maker in the kitchen storage room, as mold was found within the walls of the ice maker. Despite expectations for weekly and monthly cleanings, the ice machine appeared dirty, although no residents had reported GI issues. The facility's policy and the US FDA Food Code require routine cleaning to prevent microorganism accumulation.
A resident with type 2 diabetes was administered expired insulin lispro 11 times over a period of several days. The insulin pen was not discarded after 28 days as required, leading to multiple LVNs administering the expired medication. The DON and Administrator confirmed the error and acknowledged the risk of not following proper medication labeling and discarding protocols.
A resident's representative reported an incident where the resident's call light for incontinent care was not answered promptly. The RN documented the event but did not initiate a grievance report, contrary to the facility's policy. The Administrator confirmed that no grievance report was received, emphasizing the importance of documenting and addressing all complaints to ensure timely resolution.
A facility failed to report an allegation of neglect within the required 24-hour timeframe. A resident's representative reported that the resident did not receive timely incontinent care, but the RN did not document or report the complaint to the Administrator. This lapse in reporting could place residents at risk of not having their grievances heard and investigated.
A facility failed to remove an expired insulin lispro injection pen from the medication cart for a resident with type 2 diabetes. The pen was found to be 8 days past its expiration date, and the oversight was acknowledged by the LVN and DON. The resident was at risk of not receiving the intended therapeutic effects of her prescribed medication.
The facility failed to provide a minimum of 80 square feet per resident in two multiple resident rooms. The Administrator acknowledged the need for a waiver due to the unchanged room sizes. Room #14 had no occupants, while Room #21 had one occupant.
Resident Council Grievances Not Fully Addressed
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances and recommendations related to resident care and life in the facility. Review of resident council minutes showed repeated concerns from February 2026 through May 2026 that were not fully followed up on, including requests for earlier coffee service, coffee during meals, concerns that meat was hard and gravy was too strong, reports of dirty utensils with white residue, missing items, and complaints that dinner was arriving cold and questions about whether plate warmers were still being used. During interviews, 12 anonymous residents stated that meals were usually late and that there had been ongoing issues with the dietary department after more than three dietary staff members left. They reported that administration kept saying changes would be made, but the problems had continued for more than three months. They also stated that the former Activity Director had recently become the Dietary Manager and was still learning, and that although he was trying to make changes, there were too many issues to address. Staff interviews reflected uncertainty and inconsistency about grievance handling and resolution. The Regional Nurse stated the Activity Director was responsible for grievances and follow-up, while the ADMIN was responsible for the overall grievance process. The former Activity Director stated he helped facilitate grievances and deliver them to the ADMIN, but he did not recall the group grievances from February 2026 through May 2026 and was not sure they were fully addressed or resolved. The ADMIN stated the grievances were addressed with dietary staff, but the efforts were not correcting the issues. The facility policy required the community to listen to resident and family group views, seriously consider recommendations, attempt to accommodate them when practicable, and communicate decisions regarding proposals.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. During interviews, the ADNS, ADMIN, and DS stated that the former Activity Director had recently transitioned to the dietary department, leaving the Activity Director position vacant. The ADMIN stated the facility did not have a certified Activity Director on staff and was actively recruiting. CNA D stated his Activity Director certification had lapsed about a year earlier, that he had returned to help with the activities program on a part-time basis, and that he was providing group activities in the afternoon while the position remained unfilled. The DS stated that when he had served as the former Activity Director, he provided group and in-room activities, visited residents throughout the week, and documented those activities in the electronic medical record. He also stated that activities were necessary to promote residents’ physical and emotional well-being. Record review of the facility’s Activities Program policy stated that the activities program is directed by a qualified professional. The report shows that, at the time of the survey, the facility’s activities program was operating without a qualified Activity Director in place.
Late Meal Service Without Drinks in Dining Rooms
Penalty
Summary
The facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration, for residents in Dining Room A and Dining Room B during meal services. On 06/14/2026, at 12:02 p.m. in Dining Room A, eight unknown residents were seated without any drinks while waiting for a late lunch; the meal had not arrived, tray pass did not begin until 12:19 p.m., and residents asked about coffee but were told there was none yet. Later that day at 12:22 p.m. in Dining Room B, 12 unknown residents were also seated without drinks while waiting for lunch, and tray pass did not begin until 12:33 p.m. Similar observations were made on 06/15/2026 and 06/16/2026. On 06/15/2026, seven unknown residents in Dining Room A and 14 unknown residents in Dining Room B were observed seated without drinks while waiting for late meal trays; residents asked for coffee or a snack and were told there were no drinks yet and they would come on the tray. On 06/16/2026, meal trays were delayed in both dining rooms, and residents again waited without drinks; in Dining Room B, only 4 or 5 of 13 residents had coffee in front of them while the remaining residents waited with no drinks, and staff told residents the kitchen had run out and they would have drinks on their trays. Interviews with CNA B, Resident Council, DS, and DCS confirmed that meals were running late and that residents were not receiving drinks while waiting, and grievance records noted complaints about late meals affecting food temperatures.
Late Meal Service and Delayed Tray Delivery
Penalty
Summary
The facility failed to provide meals at the posted and scheduled times in two dining rooms, with residents seated and waiting without food or drinks while trays were still in the kitchen or arriving late. On 06/14/2026, residents in Dining Room A were observed at 12:02 p.m. with no food or drinks in front of them, and trays did not arrive until 12:19 p.m. In Dining Room B that same day, residents were observed at 12:22 p.m. waiting without food or drinks, and trays arrived at 12:33 p.m. Similar delays were observed on 06/15/2026 and 06/16/2026. In Dining Room A on 06/15/2026, residents were seated at 7:15 a.m. without food or drinks and trays arrived at 8:05 a.m.; later that day at 12:50 p.m., residents again waited without food or drinks until trays arrived at 1:00 p.m. In Dining Room B on 06/15/2026, residents were observed at 8:15 a.m. waiting for breakfast trays that arrived at 8:30 a.m., and at 1:05 p.m. waiting for lunch trays that arrived at 1:10 p.m. On 06/16/2026, lunch trays for Dining Room A left the kitchen at 12:25 p.m., while Dining Room B trays left the kitchen at 12:44 p.m.; the surveyor noted that not all lunch food was at appropriate temperatures, so close to half of the trays for Dining Room B were sent back to the dining room later, with the remaining trays leaving the kitchen at 1:15 p.m. Interviews and record review showed the facility’s posted meal schedule listed breakfast, lunch, and dinner times for Dining Rooms A and B, but staff and residents reported ongoing lateness. CNA B stated meals were frequently late and depended on who was cooking. Resident #51, who had a BIMS of 14 and was cognitively intact, stated lunch was usually late and he preferred to eat in his room. Resident #60, a new admission who was oriented to person, place, and time, stated lunch trays were late most times and he also preferred to eat in his room. The resident council stated meals were always late, and multiple staff members described delays of 15 to 45 minutes, with residents becoming upset while waiting. The ADMIN and DS acknowledged staffing changes, the absence of a Dietary Supervisor for weeks to months, and ongoing issues with meal service timing.
Kitchen Food Storage and Thawing Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation, two milk containers in the refrigerator did not have lids, a small dessert was not labeled or dated, half of a cut onion in a plastic bag had no date, half a roll of ground meat in a plastic bag had no date, and a container of soup in the refrigerator had no date. In the standing freezers, multiple items were not labeled and/or dated, including waffles, ice cream, French toast, and cups with plastic coffee lids containing a frozen pink substance. The bottom of one freezer had several packages of Butterball meat sitting directly on the freezer floor surrounded by reddish-brown frozen slush. Additional observation of the pantry found a bin of bananas and a bin of apples that were not dated. The kitchen area also contained three bottles of spaghetti sauce without labels or dates. Floors and countertops had scattered egg, bread crumbs, onion, and splattered substances that could be easily wiped off. Multiple flies were seen in the kitchen area landing on countertops, dishes, and covered food items. The kitchen also had frozen chicken in a container in the sink with hot water running over it to thaw it for lunch. During observation, steam was seen coming from the chicken where the water was running over it, and the faucet was tapped slightly to move the stream of water away from the chicken to test temperature. The water was noted to be too hot to leave a finger in the stream. The cook stated that evening staff had not pulled the chicken out to thaw the day before and that he was thawing it quickly for meal service. He acknowledged this was not the appropriate way to thaw the meat, but said he had to get lunch ready and would now be behind. The Dietary Supervisor, Administrator, Dietician, and DCS all acknowledged concerns with kitchen cleanliness, labeling, and food handling, and the facility policy required food to be labeled and dated and thawed according to correct processes.
Failure to Maintain Privacy During Ostomy Care and Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure Resident #4 received privacy during ostomy care. Resident #4 was a female admitted with diagnoses including cerebral infarction due to unspecified occlusion or stenosis, hemiplegia, and hemiparesis. Her care plan identified self-care deficit, cognitive impairment, weakness and debility, incontinence of bladder, paralysis, and the need for colostomy care with emptying of the collection bag and ensuring the appliance was intact. During an observation on 06/14/2026 at 1:01 p.m., RN G was observed providing ostomy care to Resident #4 with the privacy curtain open and the door open. Residents, visitors, and staff were observed passing by the room while the care was being provided. The ADNS observed the situation and intervened by helping with care and closing the door immediately. The facility also failed to ensure residents receiving meals in Dining Room A were treated with dignity. During an observation on 06/16/2026 at 12:40 p.m., CNA A was observed on a personal call on her cell phone while providing feeding assistance to an unidentified male resident at the table. In interviews, CNA A stated she should not have been on her cell phone while providing feeding assistance and acknowledged she had been in-serviced on cell phone use. Multiple staff members and leadership stated that privacy curtains and doors should be closed during personal care and that staff should not use personal phones while providing resident care, including feeding assistance during meals.
Quarterly MDS Assessment Not Completed on Time
Penalty
Summary
The facility failed to complete a resident’s quarterly MDS assessment within three months of the most recent comprehensive assessment. Record review for Resident #35 showed an admission record with diagnoses including Type 2 Diabetes Mellitus, dysphagia, and occlusion and stenosis of bilateral carotid arteries. The resident’s previous quarterly MDS was completed, signed, and uploaded on 02/05/2026, and the current quarterly MDS was due by 06/05/2026, but the record review showed it was not completed, signed, or uploaded. The electronic health record under the MDS tab did not show a more recent assessment submitted since 02/05/2026, and PCC showed the quarterly assessment was 12 days overdue. During interview, the RNAC stated there was not an RN on staff who could sign the MDS assessments because the DON had resigned, and she was waiting for it to be signed. The RNAC stated she knew the three-month guideline and would have the assessment signed as soon as possible. The ADMIN stated she does not really get into clinical because that is not her specialty, but the company would hold staff to the highest standards per guidelines. The facility policy stated that assessments should be updated and reviewed at least quarterly as defined in the RAI manual.
Incomplete Person-Centered Care Plan and Activity Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4 that included measurable objectives and timeframes to meet her medical, nursing, mental, and psychosocial needs. Resident #4 was admitted on [DATE] and had diagnoses including cerebral infarction due to unspecified occlusion or stenosis, hemiplegia, and hemiparesis. Her baseline care plan identified self-care deficit, cognitive impairment, weakness and debility, bladder incontinence, paralysis, and the need for a colostomy, with an intervention for ostomy care and ensuring the appliance was intact, but the care plan did not mention individual activities for a person with paralysis. Record review showed the resident’s activity assessment indicated she enjoyed group activities, getting fresh air when weather was good, religious services and practices, and morning scheduled activities in the day/activity room. The assessment also stated she would need assistance getting to and from activity functions and that she was not able to comprehend instructions for cognition/communication. On observation, she was lying in bed watching television, dressed and groomed appropriately, with her colostomy bag clipped to the bed and the call light pad within reach. She was not interviewable. Staff interviews reflected uncertainty and gaps in activity provision and care planning. A CNA stated that after the former AD transitioned to dietary, she had not seen activities for bedbound residents occurring and was unsure whether in-room activities had been provided to Resident #4 during the prior two weeks. Another CNA stated he had been providing group activities in the afternoon but had not yet provided in-room activities. The former AD stated he was unsure whether resident activities were being offered or provided to Resident #4. The RNAC stated care plans are updated at admission, quarterly, and with change of condition, that preferences and activities should have been captured on the baseline care plan, and that Resident #4’s care plan was not created as she was a new resident.
Care Plan Not Updated for Foley Catheter
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after assessment for one resident. Resident #8 had diagnoses including neuromuscular dysfunction of the bladder, and the quarterly MDS dated 05/28/2026 coded an indwelling catheter as present. Record review of the care plan dated 06/17/2026 showed no care plan for the resident’s indwelling urinary catheter, even though physician orders were in place for a Foley catheter 16Fr 10cc to be changed monthly and PRN, Foley catheter care with perineal wipes and/or soap and water as needed, and Foley output every shift. Observation on 06/15/2026 at 10:45 a.m. confirmed the resident had an indwelling urinary catheter. During interviews, the RNAC stated she was responsible for updating care plans and acknowledged there was no care plan for the Foley catheter, stating it was an oversight and should have been added when the MDS was completed. She also stated that the absence of an accurate care plan causes a breakdown of communication with nursing staff regarding the resident’s care needs. The ADNS stated she was aware the care plan had not been updated to include the Foley catheter and confirmed the RNAC was responsible for updating care plans in PCC. The facility policy stated that a comprehensive, interdisciplinary, person-centered care plan should be developed and maintained and completed no later than 7 days after completion of the comprehensive MDS assessment.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to ensure that residents received an ongoing program of activities that supported their interests and psychosocial well-being for two residents, including one resident with a history of cerebral infarction, hemiplegia, hemiparesis, cognitive impairment, weakness and debility, incontinence, and a colostomy, and another resident with CVA, non-Alzheimer's dementia, hemiplegia, hemiparesis, and severe cognitive impairment. Both residents were documented as dependent and not interviewable during observation attempts, and both had care plans that did not mention individualized activities for residents with paralysis. For the first resident, the activity assessment documented preferences such as getting fresh air when weather was good, religious services and practices, and participation in activities in the morning, afternoon, evening, and in the day/activity room. The assessment also noted the resident would need assistance getting to and from activity functions. However, the MDS tab did not show a completed Section F assessment for preferences for customary routine and activities, and the care plan did not include individualized activities for a resident with paralysis. The resident was observed lying in bed watching television, and the activity documentation for June reflected in-room activities that were inaccurately documented. For the second resident, the quarterly MDS reflected a BIMS score of 00 and dependence in functional abilities, but Section F preferences for customary routine and activities were not documented. The care plan also did not mention individualized activities for a resident with paralysis. The resident’s June activity log likewise reflected inaccurate in-room activity documentation. Staff interviews indicated that the former Activity Director had moved to dietary on 06/04/2026, the Activity Director position was vacant, and the former Activity Director had previously taken a sensory cart to bedbound residents, but staff stated that since that transition they had not seen in-room activities occurring for bedbound residents and could not recall the last in-room activities provided to the resident.
Improper incontinent and catheter care during peri-care
Penalty
Summary
The facility failed to ensure appropriate incontinent and catheter care for a resident who was incontinent of bladder and had an indwelling catheter. Resident #8 was admitted with neuromuscular dysfunction of the bladder, had a BIMS score of 13 indicating intact cognition, and was documented as always incontinent of bowel with an indwelling catheter. The care plan identified incontinent care needs and directed staff to check and change the resident upon rounds and as indicated. During observation of catheter/incontinent care, CNA C removed the resident’s soiled brief but left the draw sheet under the resident. CNA C turned the resident to the right side, cleaned the buttocks, and then turned the resident back onto the same soiled draw sheet before turning the resident again and applying a clean brief. When interviewed, CNA C stated the proper procedure was to remove the soiled draw sheet with the soiled brief, clean the resident, and apply a clean brief before turning the resident back onto her back. The ADNS stated the expectation for peri-care was to apply a clean brief after the resident had been cleaned to prevent cross-contamination and potential infection.
Insufficiently Qualified Dietary Leadership and Kitchen Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietician, for 1 of 1 kitchen reviewed. During observation on 06/14/2026 at 11:06 AM, the kitchen was found to be unclean, haphazardly organized, with staff unsure of what to do and multiple tasks unfinished. At that time, [NAME] A stated he had just been promoted to cook, that the DS was also new, that he was running behind in the kitchen, and that lunch would be late again. During interviews, ADMIN stated the DS was new and that the prior DS left around mid-April, and also stated the facility contracts its dietician with Nutritious Lifestyles. The DS stated he had not previously been in the kitchen before taking the job, had been in the role for a few weeks, and had been the activity director previously; he also stated he took the food manager course. BOM stated the DS signed his job description on 06/03/2026 to start as the DS for the kitchen. Record review of the facility dietary services policy stated food services are managed by either a qualified dietician or an experienced or qualified food service director, and if a qualified dietician is not employed full-time, the community must designate a person to serve as director of food service who receives frequently scheduled consultation from a qualified dietician. The policy also stated the director of food service must have completed a state-agency-approved 90-hour course in food service supervision, and the kitchen staff training record showed the DS completed a state-approved food manager course on 06/15/2026.
Hand Hygiene Not Performed During Meal Tray Pass
Penalty
Summary
The facility failed to maintain an infection prevention and control program for B hall when CNA B passed meal trays to 8 residents without sanitizing or washing hands before starting the tray pass and without sanitizing hands between residents. During the observation, CNA B was seen passing out meal trays on B hall and did not clean hands before beginning or between tray deliveries to the 8 residents observed. During interview, CNA B stated that not washing or sanitizing hands between residents and tasks could put residents at risk for infection and said they had held training on it, but were not sure why they did not sanitize hands and thought they may have been nervous. The ADMIN stated that staff are expected to wash or sanitize hands according to policy. Record review of the facility Handwashing/Hand Hygiene policy dated 01/2023 stated that hand hygiene is the primary means to prevent the spread of infections and that personnel should follow handwashing procedures before and after direct contact with residents, before and after handling food, and before and after assisting residents with meals.
Failure to Ensure Resident Rights: Use of Restraints Without Medical Necessity
Penalty
Summary
The facility failed to ensure that two residents admitted under the custody of the United States Marshals Service were able to exercise their rights as residents, specifically their right to be free from physical restraints not required to treat medical symptoms. Both residents were admitted while shackled at the wrists, ankles, and abdomen, and were under constant armed guard supervision. The use of these restraints was not based on medical necessity or physician orders, but rather on law enforcement requirements, as indicated in the residents' care plans and confirmed by facility staff and law enforcement personnel. Record reviews showed that both residents had significant medical diagnoses, including cerebral infarction, epilepsy, chronic pulmonary disease, and heart failure. Despite these conditions, there was no documentation of medical justification for the use of restraints, nor were there any consents or physician orders for their application. Nursing staff monitored the residents' skin integrity under the restraints but did not participate in decisions regarding the use or removal of the restraints, deferring instead to the directives of the U.S. Marshals Service. Interviews with facility staff, law enforcement, and the residents themselves confirmed that the restraints were applied and maintained by the Marshals Service, with the facility accepting the residents under these conditions. The facility's own restraint management policy emphasizes a restraint-free environment and the use of restraints only when ordered to treat medical symptoms, which was not the case for these residents. The residents remained restrained at all times, with only temporary removal of a handcuff during meals upon approval from the Marshals.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia and anxiety was administered ziprasidone, an antipsychotic medication, without proper informed consent. The resident's medical record showed she was admitted for long-term care, had a BIMS score of 0 indicating severe cognitive impairment, and required total assistance with most activities of daily living. The care plan documented the use of psychotropic medications for aggressive behavior, and physician orders prescribed ziprasidone injections as needed. The consent form for antipsychotic medication was signed by the resident's representative prior to administration. However, the form lacked any information regarding the risks and benefits of the medication, and no additional documents outlining these details were attached. The resident's representative later reported being unaware of the potential side effects and believed the medication would be administered as a pill rather than an injection. Interviews with facility staff confirmed that the consent form was incomplete and did not provide the required information about the medication's risks and benefits. Facility policy required that informed consent, including specific information about the risks and benefits of psychotropic medications, be obtained and documented prior to administration. Despite this policy, the system in place failed to ensure that the resident's representative was fully informed before the medication was given. This resulted in the administration of an antipsychotic medication without the representative's understanding of its potential side effects or the intended benefits.
Failure to Ensure Residents Are Free from Physical Restraints Not Medically Required
Penalty
Summary
The facility failed to ensure that two residents were free from physical restraints not required to treat medical symptoms. Both residents were admitted under the custody of the United States Marshal Service and were continuously shackled at the wrists, ankles, and abdomen, and supervised by armed guards. The use of these restraints was not based on medical necessity, and there were no physician orders or consents for their application documented in the residents' records. Record reviews showed that the care plans for both residents acknowledged the presence of shackles and the requirement for constant supervision by U.S. Marshals, as mandated by law enforcement and court orders. Nursing staff were instructed to monitor for skin impairment related to the restraints and to notify the Marshal's nurse case manager and assigned physician if any skin issues arose. Observations confirmed that both residents remained restrained in their rooms, with guards present at all times, and that the restraints were only temporarily loosened for specific activities such as meals. Interviews with nursing staff, facility administration, and law enforcement personnel confirmed that the restraints were applied and maintained by the Marshal Service, not the facility itself. However, the facility accepted the residents for care under these conditions without obtaining the required medical orders or consents for the restraints, as outlined in the facility's own restraint management policy. The policy emphasizes a restraint-free environment and requires that restraints only be used to treat medical symptoms with proper orders.
Failure to Transmit Discharge MDS Assessment to CMS
Penalty
Summary
The facility failed to electronically transmit an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment to the CMS system for one resident. Record review showed that the resident was originally admitted with diagnoses including type 2 diabetes mellitus, high blood pressure, and high cholesterol, and was later discharged to their home. The resident's admission MDS assessment was completed, but there was no evidence of a discharge MDS assessment or its transmittal to the CMS system, with the discharge assessment being 116 days overdue. Interviews with the MDS Nurse revealed that the discharge MDS assessment was not completed or submitted due to human error, as the resident left the facility sooner than expected and the process was missed. The Administrator confirmed that the expectation is for the MDS Nurse to process and double-check the discharge assessment for submission to CMS. Facility policy requires assessments to be conducted and transmitted within specified timeframes, but this was not followed in this instance.
Failure to Document Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate documentation and administration of blood pressure medication for a resident with multiple diagnoses, including low blood pressure and cerebral infarction. The resident had a physician's order for Midodrine with specific parameters to hold the medication if the systolic blood pressure was greater than 100. However, review of the medication administration record (MAR) showed no documentation of the resident's blood pressure results prior to administering the medication, as required by the physician's order. During medication administration, the certified medication aide (CMA) attempted to take the resident's blood pressure and administer the medication, but the resident refused both the blood pressure measurement and the medication. The CMA reported that she was aware of the medication parameters but did not document blood pressure results because there was no designated area in the electronic medical record to do so, and she had not communicated this issue to anyone. Interviews with other staff confirmed that blood pressure results were not being documented as required, despite facility policy stating that vital signs should be taken and recorded prior to medication administration when applicable.
Failure to Maintain Cleanliness of Ice Maker
Penalty
Summary
The facility failed to maintain the cleanliness of the ice maker in the kitchen storage room, as observed on 04/10/2024 at 5:06 PM. A black substance, identified as mold, was found within the walls of the ice maker. The Dietary Manager (DM) confirmed that both kitchen and maintenance staff were responsible for cleaning the ice maker monthly and acknowledged that the mold could be dangerous to residents. The Administrator and the Director of Nursing (DON) both stated that their expectation was for the ice maker to be cleaned weekly and thoroughly emptied and cleaned monthly. Despite these expectations, the ice machine appeared dirty, although no residents had reported gastrointestinal (GI) issues at the time of the interviews on 04/12/2024. The facility's policy on ice machines, which was undated, required the ice machine to be cleaned once per month or more often as needed, and the scoop and storage container to be cleaned daily. The US FDA Food Code of 2022 also mandates that surfaces of utensils and equipment contacting food, such as ice makers, must be cleaned routinely to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. The facility's failure to adhere to these standards could place residents at risk for cross-contamination and foodborne illnesses.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of expired insulin lispro to one resident. Resident #10, who has type 2 diabetes and no cognitive impairment, was administered expired insulin lispro 11 times out of a potential 17 times over a period from 04/03/2024 to 04/11/2024. The insulin pen used for Resident #10 was labeled with the date it was removed from refrigeration, indicating it should have been discarded after 28 days, but it was not. This resulted in multiple instances where expired insulin was administered by various LVNs (A, B, C, and D). The expired insulin pen was observed on the medication cart, and LVN A acknowledged the error during an interview, stating that the pen should have been discarded after 28 days outside of refrigeration. The Director of Nursing (DON) confirmed that the insulin pen should have been discarded and that the facility's policy required proper labeling and discarding of expired medications. The Administrator also agreed with the DON's assessment that residents should not receive expired medications. The facility's policy on Pharmacy Services and Provision of Medications and Biologicals, dated November 2023, was reviewed and it was noted that the community is responsible for ensuring that labeling requirements are met, including expiration dates.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances without discrimination or reprisal, and did not establish a grievance report for a complaint made by a resident's representative. Resident #17, who had a pressure ulcer, depression, and anxiety disorder, experienced an incident where her call light for incontinent care was not answered promptly. The resident's representative visited the facility late at night to address the issue but no grievance report was initiated by RN E, who documented the event in the nurse's notes but did not follow the grievance policy. During an interview, RN E acknowledged that she did not consider initiating a grievance report at the time but recognized that it should have been done to allow the Administrator to review and address the complaint. The Administrator confirmed that she had not received a grievance report for the incident and emphasized the importance of documenting grievances to ensure they are heard, investigated, and resolved. The facility's grievance policy mandates that the Administrator, as the Grievance Official, oversees the process and ensures timely and appropriate resolution of grievances. The failure to document and address the grievance could place residents at risk of not having their complaints heard and resolved. Resident #17 expressed satisfaction with the care received but had initially reported the lack of response to her call light, which was not formally documented as a grievance. The facility's policy highlights the need for all complaints, whether verbal or written, to be investigated and resolved to protect the health, safety, and welfare of residents.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure all alleged violations involving neglect were reported within the required 24-hour timeframe. Specifically, RN E received an allegation of neglect from a resident's representative but did not report the allegation to the abuse, neglect, and exploitation prevention coordinator or the Administrator. This failure was identified during a review of Resident #17's records and interviews with staff and the resident. Resident #17, who had a pressure ulcer and moderate cognitive impairment, had complained to her representative about not receiving timely incontinent care, which was not properly documented or reported by RN E. Resident #17's representative visited the facility late at night after receiving a call from the resident about the lack of response to her call light for incontinent care. RN E documented the event in the nurse's notes but did not initiate a grievance report or inform the Administrator. During an interview, RN E acknowledged that she should have generated a grievance report to allow the Administrator to review and address the complaint. The Administrator confirmed that she had not received any report of the allegation and emphasized the importance of documenting grievances for review and potential interventions. The facility's policy on preventing, identifying, and reporting abuse and neglect requires that all allegations be reported to state authorities and possibly local authorities. The failure to report the allegation of neglect within the required timeframe could place residents at risk of not having their grievances heard, investigated, and documented. This deficiency highlights a lapse in the facility's adherence to its own policies and state regulations regarding the reporting of neglect allegations.
Failure to Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically for one resident's insulin lispro injection pen. The insulin pen for a resident with type 2 diabetes was observed to be 8 days past its expiration date, having been labeled as opened on 03/05/2024 and found in the medication cart on 04/10/2024. The Licensed Vocational Nurse (LVN) acknowledged the oversight and removed the expired insulin pen from the cart. The Director of Nursing (DON) confirmed that the insulin pen should have been discarded after 28 days out of refrigeration, as per the manufacturer's guidelines. The resident involved was a female with a BIMS score indicating no cognitive impairment and was prescribed insulin lispro to manage her diabetes. The facility's policy required that medications be labeled with expiration dates, but this was not adhered to in this instance. The Administrator, while not a clinician, agreed with the DON that expired medications should not be administered to residents. The failure to remove the expired insulin pen from the medication cart could have resulted in the resident not receiving the intended therapeutic effects of her prescribed medication.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in two of its multiple resident rooms, specifically Rooms #14 and #21. This deficiency was identified through record review and interviews. The HHSC Form-3740 dated 4/9/2024 indicated that these rooms were Title 18/19 beds within a facility with a total occupancy of 60 beds. During an interview on 04/12/2024, the Administrator acknowledged that these rooms required a waiver due to their size and expressed a desire to continue the waiver as the room sizes had not changed. The facility's daily census on 04/09/2024 showed that Room #14 had no occupants, while Room #21 had one occupant.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Del Rio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Val Verde Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 4 | 0 |
| La Vida Serena Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Del Rio Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.