Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Deleon Nursing And Rehabilitation during CMS and state inspections, most recent first.
Improper Food Storage in Kitchen Freezers: Surveyors observed multiple food items in Freezer #1 and Freezer #2 that were unsealed, open to the air, and in one case not dated, including chicken, butter, hushpuppies, corn nuggets, burritos, and cookies. The DM acknowledged that open boxes were not sealed, and the ADMN stated she was unaware the food was exposed and that all residents ate from the kitchen.
The facility failed to meet food safety standards in its kitchen, with issues such as the absence of paper towels at the hand washing sink and improperly labeled and stored food items. Observations revealed several food items without labels or proper storage, increasing the risk of contamination. Interviews with the DM and Dietician confirmed these deficiencies, despite recent staff training on proper procedures.
The facility failed to conduct PASRR evaluations for residents with mental illness, including those with psychosis and major depressive disorder. Three residents with diagnoses of psychosis, major depressive disorder, and dementia did not have PASRR evaluations despite positive PASRR Level 1 screenings. The MDS coordinator misunderstood the qualification criteria for mental illness in PASRR evaluations, leading to a lack of necessary referrals. The facility's administrator acknowledged that lack of knowledge and oversight contributed to this deficiency.
The facility failed to ensure proper storage of oxygen equipment for two residents requiring oxygen therapy. Oxygen tubing and nasal cannulas were found improperly placed on a bedside table and the floor, not stored in plastic bags as per facility policy. The DON confirmed that such practices could lead to infection, as the tubing should be replaced if found on the floor. This oversight placed residents at risk for respiratory illnesses.
A resident with severe cognitive impairment and on a mechanically altered diet was served regular melon instead of pureed melon, contrary to physician's orders. The error was observed during meal service, and staff oversight was identified as the cause. The facility's policy required verification of diet orders to prevent aspiration, which was not followed.
The facility did not ensure a nursing assistant was certified as required by state laws. The NA, hired in 2022, had not passed the CNA certification exam despite multiple attempts. The DON expected the NA to complete an online course and pass the test, while the ADMN attributed the failure to inadequate preparation from a high school program. The facility's job description required certification within 120 days, which was not met.
An LVN failed to perform proper hand hygiene while feeding two residents, including a resident with Alzheimer's and severe cognitive impairment, in an LTC facility. The LVN did not sanitize her hands after touching one resident and wiping their mouth before assisting another resident, contrary to the facility's infection control policy. This placed residents at risk of infections.
The facility did not post daily staffing information in a prominent place on two reviewed days. Observations showed no staffing information at the nurses' station or elsewhere. The DON was unaware of the requirement and believed it would not harm residents, attributing the failure to a lack of awareness and policy.
The facility failed to provide two residents or their representatives with a paper copy of the Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services before covered days were exhausted. Despite verbal explanations, the NOMNC forms were not mailed, leaving residents unaware of their right to appeal the decision to end Medicare coverage.
Improper Food Storage in Kitchen Freezers
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. During an observation on 9/23/25 at 9:45 AM, surveyors found multiple food items in Freezer #1 and Freezer #2 that were unsealed and/or open to the air, including a bag of chicken legs, a bar of butter that was unsealed and not dated, a bag of hushpuppies, a bag of corn nuggets, a bag of chicken thighs, a box of burritos, and a sheet tray of red velvet chocolate chip cookies. During the same observation and interview, the DM stated that an open box would not be considered sealed and acknowledged that all food needed to be covered and sealed so residents would not get sick from contaminants getting on the food. Later, the ADMN stated she did not know the food was exposed in the kitchen and said it was her responsibility as well as the DM's to keep all food covered and safe. She also stated that all residents ate from the kitchen and that residents could have eaten contaminated foods resulting in residents getting sick.
Food Safety and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The deficiencies included the absence of paper towels at the kitchen hand washing sink, which is essential for proper hand hygiene and preventing cross-contamination. Additionally, several food items were improperly stored without labels indicating a description or open date, which is crucial for ensuring food safety and preventing foodborne illnesses. During the observation, it was noted that an opened container of cake frosting, a bag of cream soup base, and various frozen and refrigerated items were not labeled with a description or open date. Some items, such as frozen pie dough sheets and pink frozen meat cutlets, were not stored in sealed containers, exposing them to air and potential contamination. Furthermore, a foam cup with a pink substance and plastic dishes with a yellow substance were found in the refrigerator without proper lids or labels. Interviews with the Dietary Manager (DM) and Dietician revealed that there was an expectation for food to be stored in sealed containers and labeled with open dates. The DM acknowledged the lack of paper towels and improper food storage, stating that staff had been in-serviced on these procedures. The Dietician also emphasized the importance of labeling and proper storage to prevent cross-contamination and foodborne illnesses. The facility's policies on food storage and hand washing, as well as the FDA Food Code, were referenced to highlight the standards that were not met.
Failure to Conduct PASRR Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to refer all level II residents and those with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions for a level II resident review upon a significant change in status assessment. This deficiency was identified for three residents who were reviewed for PASRR. The facility did not follow up with the local authority for PASRR Level II determination when these residents' PASRR Level 1 Screening indicated they were positive for mental illness. Resident #5, a female with diagnoses of psychosis, major depressive disorder, and dementia, had no evidence of a PASRR evaluation in her medical record. Her quarterly MDS indicated intact cognition and active psychiatric disorders. Similarly, Resident #12, a female with psychosis, major depressive disorder, and dementia, also lacked a PASRR evaluation, with her quarterly MDS showing severe cognitive impairment and active depression. Resident #37, a male with psychosis, major depressive disorder, and dementia, had no PASRR evaluation, with his annual MDS indicating severe cognitive impairment and active depression. Interviews with the MDS coordinator revealed a misunderstanding regarding the qualification of major depressive disorder as a mental illness for PASRR purposes. The coordinator was unsure if a new diagnosis should trigger a PASRR evaluation and was unaware of the rules for scheduling such evaluations after a new mental illness diagnosis. The facility's administrator expected staff to follow PASRR policy and acknowledged that lack of knowledge and oversight led to the failure.
Failure to Properly Store Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy, as observed during a survey. For one resident, oxygen tubing with a nasal cannula was found on a bedside table without being placed in a plastic bag when not in use, contrary to the facility's policy. This resident had a history of anorexia, dysphagia, cognitive communication deficit, and hypertension, and was prescribed oxygen at 2 liters per minute to maintain oxygen saturation above 90%. The care plan indicated that the resident frequently removed the oxygen, and staff were instructed to notify the nurse if the oxygen was off the resident. For another resident, the oxygen tubing with a nasal cannula was found on the floor, also not stored in a plastic bag when not in use. This resident had diagnoses including chronic obstructive pulmonary disease, hypertension, and anxiety, with orders to use oxygen at 2-3 liters per minute. The facility's Director of Nursing (DON) acknowledged that oxygen tubing should not be left on tables or floors and should be replaced if found on the floor to prevent infection. The facility's policy on oxygen administration emphasized changing tubing when visibly contaminated, but this was not adhered to, placing residents at risk for respiratory illnesses.
Failure to Provide Pureed Diet to Resident
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of a resident, specifically Resident #22, who was on a mechanically altered diet due to severe cognitive impairment and abnormal weight loss. Despite having a physician's order for a fortified/enhanced pureed diet, Resident #22 was served a bowl of regular melon instead of pureed melon. This incident was observed during a meal service, where the resident attempted to eat the melon but then removed it from her mouth without showing signs of distress. Interviews with the Registered Nurse Coordinator (RNC) and the Dietician revealed that the resident should have been served pureed melon, and the error was attributed to oversight by the kitchen and dining room staff. The Dietician acknowledged that the kitchen staff should have verified the resident's specific diet before the tray left the kitchen, and the dining room staff should have ensured the correct diet was served. The facility's policy on feeding, dated February 14, 2007, emphasized the importance of confirming appropriate diets to prevent aspiration, highlighting a lapse in adherence to this policy.
Failure to Ensure Nursing Assistant Certification
Penalty
Summary
The facility failed to ensure that a nursing assistant (NA B) was certified in accordance with state laws, as required for professional staff. NA B was hired on 08/30/2022, but her employee file showed no evidence of CNA certification. During an interview, the Director of Nursing (DON) stated that NA B was not a Certified Nurse Aide (CNA) and had failed the certification exam twice, with one more attempt remaining. The DON expected NA B to complete an online course and pass the test promptly, noting that NA B always worked with a certified CNA, which the DON believed mitigated any effect on residents. The Administrator (ADMN) expected NAs to become certified quickly and indicated that the failure was due to NA B's inadequate preparation from a high school program. The facility's job description for a Student Nurse Aide, dated 2014, required certification within 120 days, which NA B had not achieved.
Inadequate Hand Hygiene During Resident Feeding
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A while feeding residents. During an observation, LVN A was seen assisting two residents with their meals without performing proper hand hygiene. After touching one resident and wiping their mouth, LVN A did not sanitize her hands before continuing to assist another resident. This lapse in hand hygiene occurred despite the facility's policy requiring hand hygiene before and after assisting a resident with meals and upon contact with a resident's intact skin. Resident #22, a female with Alzheimer's Disease and severe cognitive impairment, was directly affected by this deficiency. She was on a fortified/enhanced pureed diet and required assistance with eating due to her ADL self-care performance deficit. The failure to perform hand hygiene placed residents, including Resident #22, at risk of infections, particularly during dining and respiratory care activities. LVN A admitted to not thinking about hand hygiene during the feeding process, indicating a lack of adherence to the facility's infection control policies.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted in a prominent place readily accessible to residents and visitors on two of the three days reviewed. Specifically, on 08/18/2024 and 08/19/2024, observations revealed that no daily nursing staffing information was posted at the nurses' station or any other place in the facility. During an interview on 08/20/2024, the Director of Nursing (DON) stated she was unaware of the requirement to post daily staffing information and believed that the absence of this information would not harm residents. The DON mentioned that family members, residents, or visitors could inquire about the staff on duty. The failure to post staffing information was attributed to the DON's lack of awareness of the requirement and the absence of a policy for nurse staff posting, despite following federal regulations.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that residents were informed about their Medicare/Medicaid coverage and potential liability for services not covered. Specifically, the facility did not provide a paper copy of the Notice of Medicare Non-Coverage (NOMNC) to two residents, Resident #8 and Resident #30, or their representatives, when they were discharged from skilled services before their covered days were exhausted. This failure was identified during interviews and record reviews, which revealed that the residents or their representatives were not adequately informed about their right to appeal the decision to end Medicare coverage. Resident #8, a female with moderate cognitive impairment, was admitted with multiple diagnoses including enterocolitis, sepsis, and hypertension. Her records indicated that she received Medicare Part A Skilled Services, and her last covered day was documented. However, there was no evidence that the NOMNC form was given to her or her representative, despite a signature being present on the form. During an interview, Resident #8's family member stated that they did not recall receiving any paperwork or a phone call about the Medicare coverage ending, nor did they receive an appeal number. Resident #30, a male with severe cognitive impairment and multiple health issues, also received Medicare Part A Skilled Services. His records showed that the facility spoke with his family member to explain the NOMNC, but there was no signature on the form, and no evidence that the form was provided to them. The family member confirmed in an interview that they did not receive any paperwork, although they remembered a conversation about the coverage ending. The facility's MDS coordinator and administrator acknowledged that verbal explanations were given, but they did not mail the NOMNC forms, believing verbal communication was sufficient.
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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 De Leon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Estate Long Term Care | 8.5 mi | ★★★★★ | 0 | 0 |
| Western Hills Healthcare Residence | 15.7 mi | ★★★★★ | 0 | 0 |
| Stephenville Nursing And Rehabilitation | 18.6 mi | ★★★★★ | 6 | 0 |
| Avir At Stephenville | 19.2 mi | ★★★★★ | 7 | 0 |
| Lone Star Rehabilitation & Wellness Center | 19.6 mi | ★★★★★ | 9 | 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.