Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Care Choice Of Boerne during CMS and state inspections, most recent first.
An LPN left a medication cart computer unlocked on one hall, exposing resident names and room numbers, and another LPN left a cart computer unlocked on another hall while a resident's eMAR remained open during blood pressure collection. Both staff stated they usually lock or hide the screen but did not do so at the time, and facility leadership stated computers should be secured when staff step away.
Medication administration times were not followed, resulting in a 100% error rate during observation. An LPN gave multiple residents’ scheduled meds late, including meds for dementia, DM, depression, HTN, gout, constipation, pain, and vitamin supplementation. The facility policy required meds to be given within one hour of the prescribed time, and staff stated breakfast and scheduling practices contributed to the delays.
An LPN left a medication cart unlocked and unattended in the hallway while administering medications to a resident at bedside. The cart remained unsecured for about two minutes, despite the facility policy requiring the cart to be kept closed and locked when out of sight of the medication nurse or aide.
Failure to report abuse, neglect, and injury events: The DON and ADM did not report a self-inflicted injury by a resident with dementia, MDD, bipolar disorder, and anxiety after she ingested OTC eye drops and was sent to the hospital for a psych eval. The facility also did not report an incident where one resident struck another with a walker, and did not report an injury of unknown origin involving a resident with severe cognitive impairment who later had a contusion, pelvic fx, and subdural hemorrhage.
Insufficient Qualified Food and Nutrition Leadership: The facility lacked a qualified dietitian or clinically qualified nutrition professional on a full-time basis and had no qualified director of food and nutrition services for almost a year. The designated FSS said she was not qualified for the role and was still working toward CDM certification. Consultant dietitian notes showed resident assessments and MNAs were completed for some admissions, but also documented that the FSS was not completing MNAs due to time constraints and that lunch service included inadequate portions of pureed foods, with staff needing training on diet spreadsheets and proper portions.
Failure to Investigate and Report Self-Inflicted Injury: A resident with dementia and multiple psychiatric diagnoses disclosed self-harm after ingesting over-the-counter eye drops, and the DON arranged ER evaluation. However, the ADM did not recall the event, the DON did not believe it required reporting or an investigation, and the record showed no evidence that the allegation was reported to the state or thoroughly investigated as required by policy.
Failure to Complete Significant Change MDS After Self-Harm Incident: A resident with dementia, depression, anxiety, bipolar disorder, and insomnia had a self-injury event after disclosing suicidal thoughts and ingesting eye drops. She was sent to the ER and later followed by psych services, but the facility did not complete a Significant Change MDS or interdisciplinary review after the event, despite documentation that the incident was a major deviation from her baseline and staff disagreement about whether it met criteria for a significant change.
Failure to update the care plan after a self-inflicted injury: A resident with dementia, depression, anxiety, bipolar disorder, and insomnia disclosed suicidal thoughts and drank over-the-counter eye drops. She was sent for ER/psych eval and later had severe anxiety, depression, and guilt documented, but the care plan only addressed depression and did not include suicide risk, self-harm, or suicidal ideation interventions, and no interdisciplinary review or significant change assessment was completed.
A Humalog insulin vial for a resident was found in the 200-hall med cart after its 28-day open-vial period had expired. The DON was unsure of the insulin storage policy, and an LVN said the vial should have been discarded but the folded label blocked her view. The LVN also stated the resident had received medication from the vial.
Failure to use PPE during incontinence care: A resident with a stage 3 sacral pressure ulcer was on EBP for high-contact care, and a sign and PPE cart were present outside the room. Two CNAs were observed providing incontinence care without gowns, and both later stated they should have worn PPE and had received infection control and isolation training. The DON stated facility policy and expectation was that staff use proper PPE when providing care.
A resident with severe cognitive impairment and hearing loss was not provided with effective communication strategies after losing her hearing aids. Although some staff began using written communication, this approach was not consistently communicated or included in the care plan, resulting in inconsistent support and ongoing communication challenges for the resident.
A resident with dementia and hearing loss was assessed as using hearing aids and having severe cognitive impairment, despite documentation that her hearing aids were lost and her ability to respond was impacted. The care plan was not updated to reflect the loss of hearing aids or to include alternative communication strategies, and staff interviews confirmed a lack of awareness and communication about effective interventions.
A resident with dementia and hearing loss lost her hearing aids, resulting in increased communication difficulties. Although staff began using a whiteboard to communicate, the care plan was not updated to reflect this intervention or the resident's changed needs. The interdisciplinary team did not revise the care plan after the significant change, and documentation continued to reference hearing aids that were no longer available.
Two residents in a facility were observed with malfunctioning anti-rollback devices on their wheelchairs, posing a fall risk. One resident, with severe cognitive impairment, had a missing safety prong on the left wheel, while another resident with Parkinson's disease had a missing prong on the right wheel. Staff were unaware of the duration of the malfunction, and the facility's administration acknowledged the issue.
Two residents experienced significant medication administration delays due to an LPN's late start following a breakfast safety monitoring assignment. One resident with Alzheimer's received memantine 45 minutes late, while another with heart disease and seizures received Valsartan, Levetiracetam, and Divalproex 54 minutes late. The facility's policy requires medication to be administered within one hour of the prescribed time.
The facility failed to maintain accurate medical records for three residents, as their Out-of-Hospital Do Not Resuscitate (OOH DNR) order forms were not properly uploaded into their electronic medical records (EMR). One resident's form was mistakenly placed in another's record, while two others had missing forms until identified by a surveyor. The Director of Nursing acknowledged the oversight, emphasizing the importance of accurate records for honoring residents' end-of-life wishes.
A facility's medication error rate was 8.0%, exceeding the acceptable threshold, due to late administration of medications to a resident with diabetes and heart failure. An LVN administered metformin and metoprolol 30 minutes late due to additional duties, without notifying supervisors. The facility's policy requires timely administration within one hour of the prescribed time.
A facility failed to ensure proper hand hygiene during blood glucose monitoring and insulin administration for a resident with diabetes. An LVN did not perform hand hygiene between glove changes, contrary to facility policy and CDC guidelines. The resident required regular monitoring and insulin due to diabetes, and the LVN attributed the lapse to nervousness during observation.
A resident with severe cognitive and visual impairments was involved in an altercation with another resident known for aggressive behaviors, resulting in the former falling to the floor. Despite the aggressive resident's documented history of inappropriate behaviors, the facility failed to prevent the incident, highlighting a deficiency in protecting residents from abuse.
A resident with dementia and other conditions was injured when an agency nurse aide attempted a mechanical lift transfer alone, contrary to the care plan requiring two staff members. The resident became agitated, causing the lift to tip over, resulting in a head laceration and femur fracture. The facility's policy recommended two assistants for such transfers.
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included necessary interventions to prevent coffee spills. Despite the resident's cognitive decline and previous incident of spilling coffee, the care plan was not updated to reflect his need for assistance with handling his coffee cup and ensuring the lid was on tightly.
Unsecured Medication Cart Computers Exposed Resident Information
Penalty
Summary
The facility failed to protect the confidentiality of personal and medical records for two LPNs observed on the 100-Hall and 200-Hall medication carts. On 05/27/2026 at 09:35 a.m., a computer screen on a medication cart outside a room on 100-Hall was observed unlocked and unsupervised with resident names and room numbers visible. No residents or visitors were in the immediate area. LPN A was observed walking down the hall from the nurses' desk within 30 seconds and then locked the computer. During interview, LPN A stated she usually locks the computer before leaving it, acknowledged that she had left it unlocked, and explained she had stepped away to obtain a catheterization tray after entering vitals for a resident. During a medication administration observation on 05/27/2026 from 10:17 a.m. to 10:28 a.m., LPN B reviewed Resident #3's ordered medications outside the resident's room and then entered the room to obtain the resident's blood pressure while leaving the computer on the medication cart unlocked and unattended for approximately 3 minutes. Resident #3's electronic MAR remained open during that time, and no residents or visitors were observed in the immediate area when LPN B returned. LPN B stated she usually hides the screen when entering a resident's room, did not realize she had not locked it, and said it was important to hide the screen for HIPAA and resident privacy. The ADMIN and DON stated staff should secure or lock the computer when not right in front of it, and the facility policy stated unauthorized release, access, or disclosure of resident information is prohibited.
Medication Administration Times Not Followed
Penalty
Summary
The facility failed to ensure that medication administration was completed within the prescribed time frames, and survey observations identified a medication error rate of 100% based on 25 out of 25 opportunities involving four residents and three LPNs. The report states that medications were administered late for each observed resident, with the facility policy requiring medications to be given within one hour of the prescribed time unless otherwise specified. The facility’s own policy also states that medications are to be administered in accordance with prescriber orders and that medication administration times are determined by resident need and benefit, not staff convenience. For one resident with diagnoses including unspecified dementia, adjustment disorder with mixed anxiety and depressed mood, and constipation, Namenda and Pataday were scheduled for 8:00 a.m. but were administered at 9:44 a.m. The resident’s record showed active orders for Namenda 10 mg twice daily and Pataday eye drops once daily for dry eyes. During observation, the LPN preparing the medications acknowledged that the medications were late and stated the resident often did not take medications until after breakfast, which could result in late administration. For a second resident with type 2 diabetes mellitus, anxiety disorder, depression, and major depressive disorder, Escitalopram Oxalate, Glipizide, and Metformin HCl were scheduled for 8:00 a.m. but were administered at 10:17 a.m. For a third resident with constipation, type 2 diabetes mellitus, hypertension, and gout, acetaminophen, allopurinol, amlodipine besylate, Jardiance, Lidoderm patch, metformin HCl, MiraLax, pregabalin, and senna were scheduled for 8:00 a.m. but were administered at 10:28 a.m. The LPN stated that most residents’ medications were scheduled for 8:00 a.m., that nurses had an hour before and after the scheduled time, and that breakfast interrupted medication administration. The LPN also stated that some medications scheduled later in the morning were prioritized earlier to avoid being given too close together if the 8:00 a.m. medications were delayed. For a fourth resident with type 2 diabetes mellitus, gout, anemia, hypertension, GERD, major depressive disorder, and vitamin deficiency, folic acid, Pepcid, allopurinol, iron, multiple vitamins-minerals, thiamine, Lexapro, metformin HCl, magnesium oxide, metoprolol tartrate, and zinc were scheduled for 9:00 a.m. but were administered at 10:18 a.m. The ADMIN stated his understanding was that staff had one hour before and after the scheduled time to administer medications, and the DON stated staff had an hour before and after the scheduled time per facility procedure. The DON also stated late administration could affect the next dose if the medication was given too close to the next scheduled administration time.
Unsecured Medication Cart During Administration
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments with access limited to authorized personnel when LPN B left the 200-Hall medication cart unattended and unlocked during medication administration for about two minutes. During an observation on 05/27/2026 from 10:17 a.m. to 10:28 a.m., LPN B prepared Resident #3's medications, picked up the resident's medications in a cup at about 10:26 a.m., left the cart in the hallway next to the resident's room, and entered the room to administer the medications at bedside. The cart was observed to be unlocked and unattended, and there were no residents or visitors in the immediate area. During interview, LPN B stated she usually locks the cart when entering a resident's room but did not realize she had not locked it on this occasion. She stated that if a patient came by, they could open it up, though the narcotics were secured separately and the punch cards would be difficult for residents to access. The ADMIN stated the medication cart should be secured as soon as nursing staff pull away from it, and the DON stated staff were expected to lock the cart anytime they walked away from it. The facility policy titled, Administering Medications, stated the medication cart is kept closed and locked when out of sight of the medication nurse or aide.
Failure to Report Abuse, Neglect, and Injury Events
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation were reported immediately or within the required timeframes to the administrator and other officials, including the State Survey Agency. The report identified that the Director of Nursing did not recognize a self-inflicted injury by a resident as an alleged neglect event on 9/16/2025, and the Administrator was not notified and did not report the event within 24 hours. The resident had diagnoses including dementia, mild cognitive impairment, major depressive disorder, generalized anxiety disorder, bipolar disorder, and insomnia, and the incident involved the resident drinking a half bottle of over-the-counter eye drops after stating she wanted to harm herself. The resident was assessed by the DON, confirmed the ingestion, and was transported by EMS to the hospital for a psychiatric evaluation. Hospital documentation reflected a high suicide risk level. Facility staff later described the event as a cry for help or an acute incident, and the DON stated she did not believe it needed to be reported to the state because the resident was being monitored by psych services and social work. The record review showed no indication that the incident was reported to the Administrator within 24 hours or reported to the State Survey Agency within the required timeframe. The facility also failed to report an incident in which one resident intentionally struck another resident with a walker on 8/31/2025. The incident report described the resident ramming a rolling walker into another resident’s legs while using profanity. The DON and Administrator stated the event was not reported because it was common behavior, did not result in harm, and they believed intent to harm was required for reporting. In addition, the facility failed to report an injury of unknown origin involving a resident with severe cognitive impairment and a history of traumatic subdural hemorrhage. The resident had a fall-related event on 7/25/2025, later showed a large contusion to the eyebrow, and was sent to the hospital where she was diagnosed with a pelvic fracture and subdural hemorrhage. The DON stated the unwitnessed fall was not reported because the resident said she fell and the resident had frequent falls.
Insufficient Qualified Food and Nutrition Leadership
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 dietitian, for 1 of 1 kitchen reviewed. The report states the facility had been without a qualified director of nutritional services since February 2025 and did not employ a qualified dietitian or other clinically qualified nutrition professional on a full-time basis. The person designated as the director of food and nutrition services did not have the qualifications required for that role, and the administrator acknowledged the facility had been without a qualified director for almost a year. During interview, the food service supervisor said she did not have the qualifications to serve as the director of food and nutrition services and was working toward certified dietary manager status after accepting the full-time position when the prior supervisor retired. The administrator said he did not know the dietitian could not designate her because she lacked the needed qualifications, and he stated she was near the end of her training. Record review showed the consultant dietitian completed resident assessments and monthly nutrition assessments for new admissions, but also documented that the food service supervisor was not completing MNAs due to time constraints. Additional consultant reports noted inadequate portions of pureed foods during lunch service, limited discussion with the cook because of a language barrier, and the need for training on diet spreadsheets and proper portions.
Failure to Investigate and Report Self-Inflicted Injury
Penalty
Summary
The facility failed to thoroughly investigate an alleged self-inflicted injury involving a resident with a history of dementia, mild cognitive impairment, major depressive disorder, generalized anxiety disorder, bipolar disorder, and insomnia. The resident’s record showed she was admitted and re-admitted to the facility, and her psychiatric history included ongoing mental health services and medication management. An incident report documented that the DON was informed by a talk therapist that the resident had disclosed wanting to harm herself and had said she drank a bottle of eye drops the day before. The resident confirmed during assessment that she drank a half bottle of over-the-counter eye drops because she was struggling with her bipolar disorder. The incident report further documented that the DON immediately assessed the resident, who was alert and oriented to her situation, and arranged for emergency room evaluation. The hospital encounter note reflected a high suicide risk assessment. The resident’s care plan and MDS reflected psychiatric diagnoses and use of antipsychotic, antianxiety, and antidepressant medications, but the record reviewed did not show that the self-inflicted injury was documented as self-harm. Facility records from 2/10/2026 through 2/12/2026 showed no indication that the incident was reported to the administrator within 24 hours, no indication that it was reported to the State Survey Agency within the required timeframe, and no indication that the facility initiated an investigation of the alleged violation. During interviews, the ADM stated he did not recall the self-harm incident and did not investigate it. The DON stated she knew about the incident, believed it did not need to be reported to the state, and did not require an investigation because the resident was monitored by psych services and social work and was stable. The social worker described the event as a cry for help and not part of the resident’s baseline behavior. The facility policy stated that allegations of abuse, neglect, exploitation, misappropriation, or injury of unknown source are to be immediately reported and thoroughly investigated, with findings documented and reported, but the record did not show that this occurred for the resident’s self-inflicted injury.
Failure to Complete Significant Change MDS After Self-Harm Incident
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment within 14 days after it determined, or should have determined, that Resident #2 had a significant change in physical or mental condition following a self-injury incident. Resident #2 was admitted and re-admitted to the facility with diagnoses including dementia, mild cognitive impairment, major depressive disorder, generalized anxiety disorder, bipolar disorder, and insomnia. Her quarterly MDS reflected a BIMS score of 15, independent self-care and mobility, and active psychiatric diagnoses with antipsychotic, antianxiety, and antidepressant medications. The record showed that on 9/16/2025, the DON was informed by the talk therapist that Resident #2 had disclosed wanting to harm herself and had reported drinking a bottle of eye drops the day before. Resident #2 confirmed that she drank a half bottle of over-the-counter eye drops because she was struggling with her bipolar disorder. The DON assessed her as alert and oriented to her situation, noted nausea and vomiting after the ingestion, and sent her to the ER for evaluation. The hospital encounter documented a high suicide risk assessment. Subsequent psychiatric follow-up documented severe anxiety, depression, and guilt feelings, and continued monitoring for recent suicidal ideation. The facility record reflected that no significant change in status assessment or interdisciplinary review was completed after the self-inflicting injury/self-harm incident, which was described as a major deviation from Resident #2's established baseline health. The MDS Coordinator stated she did not believe the event met criteria for a significant change in status because the resident was deemed safe by psychiatry and the hospital, and she viewed it as a one-off occurrence. The DON stated the incident was a significant change to the resident's baseline and that an RAI assessment should have been completed following the event. Facility policy stated that if a significant change in physical or mental condition occurs, a comprehensive assessment will be conducted as required by OBRA regulations and the MDS RAI manual.
Failure to Update Care Plan After Self-Inflicted Injury
Penalty
Summary
The facility failed to ensure that Resident #2’s comprehensive care plan was reviewed and revised by the interdisciplinary team after assessment findings and after a self-inflicted injury incident. Resident #2 was admitted with diagnoses including dementia, mild cognitive impairment, major depressive disorder, generalized anxiety disorder, bipolar disorder, and insomnia. Her psychiatric assessment on 9/10/2025 documented that she was doing okay, with no current suicidal ideation and no current symptoms of depression or mood changes. On 9/16/2025, an incident report documented that the DON was informed by the talk therapist that Resident #2 had disclosed wanting to harm herself and had drank a bottle of eye drops. Resident #2 confirmed that she drank a half bottle of over-the-counter eye drops because she was struggling with her bipolarism. The DON immediately assessed her, arranged for emergency room evaluation, and the resident was transported for psychiatric evaluation. The hospital encounter note documented a high suicide risk assessment. A later psychiatric assessment on 9/22/2025 documented severe anxiety, depression, and guilt feelings, and noted continued verbal no self-harm contract and continued discussion of recent suicidal ideation and trauma. Resident #2’s care plan, revised on 9/22/2025 and again on 12/22/2025, addressed depression related to major depressive disorder and stated she would exhibit indicators of depression, anxiety, or sad mood less than daily, but it did not include care planning related to suicide risk, self-inflicted injury, or suicidal ideation. Review of the EMR from 2/10/2026 to 2/12/2026 showed no significant change in status assessment or interdisciplinary review after the self-inflicted injury incident. Facility staff stated the incident should have been care planned, but the care plan was not updated to reflect the self-harm event or related interventions.
Expired Opened Insulin Vial Kept in Medication Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when a Humalog insulin vial for Resident #8 remained in the medication cart after its 28-day open-vial period had expired. During an observation on 2/10/2026 at 8:15 AM, the DON and surveyor found the 200-hall medication cart contained a Humalog insulin vial with an opened-on date of 12/29/2025. The DON was unsure of the facility policy for insulin storage after opening. In a later interview, an LVN stated the facility policy was to keep insulin for 28 days after opening and that the vial should have been discarded on 1/26/2026; she also stated the label had been folded in a way that blocked her view and she did not notice it. She further stated Resident #8 had received medication from the vial. Record review showed the facility policy required multi-dose vials to be dated and discarded within 28 days unless the manufacturer specified otherwise.
Failure to Use PPE During Incontinence Care
Penalty
Summary
The facility failed to 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 6 residents reviewed for infection control. Resident #4 was an [AGE] year-old female admitted to the facility on [DATE], with a diagnosis including a stage 3 pressure ulcer of the sacral region. Her quarterly MDS dated 10/31/2025 showed a BIMS score of 0 and that she was rarely understood. Her order summary dated 2/12/2026 directed staff to place her on Enhanced Barrier Precautions for direct care services including dressing or bathing, transferring, changing linens, assisting with toileting, accessing indwelling medical devices, providing wound care, and other high-contact resident care activities, and her care plan noted she was on enhanced barrier precautions related to a wound. During an observation on 2/11/2026 at 9:36 AM, a sign on Resident #4's doorway indicated she required EBP precautions, and a cart with PPE supplies was observed in the hallway near her room. CNA A and CNA B were observed performing incontinence care without donning PPE. In an interview at 9:45 AM, both CNAs stated they should have put on gowns before entering the room, said they were nervous about the observation and forgot, and confirmed they had received training from the facility about infection control and isolation precautions. In an interview with the DON at 10:00 AM, she stated the expectation and facility policy was that staff would utilize proper PPE when providing care for residents.
Failure to Update Communication Strategies for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and significant hearing loss was provided with effective communication strategies after the loss of her hearing aids. The resident, diagnosed with dementia, Alzheimer's disease, depression, and muscle weakness, had a history of losing her hearing aids, which were not replaced after the most recent loss due to cost and repeated incidents. Despite the resident's care plan initially including interventions for hearing aid use and communication strategies, there was no documented update or revision to the care plan after the hearing aids were lost, nor were alternative communication methods formally implemented or communicated to all staff. Observations and interviews revealed that staff had to speak loudly and repeat questions for the resident to understand, and some staff began using written communication, such as a whiteboard, to facilitate interaction. However, this intervention was not consistently communicated to or utilized by all staff, and it was not incorporated into the resident's care plan. Key staff members, including the social worker and MDS nurse, were unaware of the use of the whiteboard until the time of the survey, and the care plan did not reflect this new communication strategy. The lack of a coordinated approach and failure to update the care plan resulted in inconsistent communication support for the resident. Documentation in the resident's medical record and progress notes confirmed ongoing difficulties with communication, including challenges during assessments and daily interactions. Staff interviews indicated that while some were aware of the resident's needs and attempted to adapt, there was no systematic or care-planned approach to address the resident's hearing loss after the loss of her hearing aids. This deficiency in updating and implementing effective communication strategies directly impacted the resident's ability to convey her needs and participate in her care, as observed and reported by both staff and the resident herself.
Inaccurate MDS Assessment and Failure to Update Care Plan for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's cognitive status and use of hearing aids. The resident, who had diagnoses including unspecified dementia, Alzheimer's disease, depression, and muscle weakness, experienced a significant change in cognitive status as recorded in the MDS assessment. However, the assessment inaccurately indicated that the resident was using hearing aids, despite documentation that the hearing aids had been lost prior to the assessment period. The MDS also did not accurately reflect the resident's true cognitive abilities, as the Brief Interview for Mental Status (BIMS) was conducted while the resident was missing one or both hearing aids, impacting her ability to respond to questions. Review of the resident's care plan and electronic medical record revealed that interventions for communication strategies were not updated after the loss of the hearing aids. The care plan continued to reference the use of hearing aids and did not include alternative communication methods, such as the use of a whiteboard, which staff later reported as effective. Progress notes and interviews with staff confirmed that the resident had a history of losing hearing aids and that the family was no longer able to replace them. Despite this, there was no documentation of care plan revisions or updated interventions to address the resident's hearing loss and communication needs after the hearing aids were lost. Interviews with facility staff, including the social worker, MDS nurse, and DON, revealed a lack of awareness and communication regarding the use of alternative communication methods and the need to update care plans and assessments accordingly. Staff acknowledged that the resident's low BIMS scores were likely influenced by her inability to hear the questions, and that the care plan should have been revised to reflect her current status and needs. The facility's policies require that assessments and care plans be accurate, comprehensive, and updated in response to significant changes in a resident's condition, but these requirements were not met in this case.
Failure to Update Care Plan After Loss of Hearing Aids
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident with significant hearing loss and cognitive impairment. The resident, who had a history of dementia, Alzheimer's disease, depression, and muscle weakness, experienced a significant change in her cognitive status as reflected in her MDS assessments. Despite the loss of her hearing aids, which were documented as missing and not replaced due to repeated losses, the care plan was not updated to reflect new communication strategies or interventions to address her hearing deficit. Multiple assessments and interviews revealed inconsistencies and inaccuracies in the documentation of the resident's cognitive and communication abilities. The resident's BIMS scores declined significantly after the loss of her hearing aids, and staff interviews confirmed that the resident had difficulty hearing and communicating without them. Staff began using a whiteboard to facilitate communication, but this intervention was not documented in the care plan, nor was it communicated to all relevant team members. The care plan continued to reference the use of hearing aids and did not include alternative communication methods after the aids were lost. Interviews with staff, including the DON, MDS nurse, social worker, and therapy staff, confirmed that the loss of the hearing aids and the use of alternative communication methods were discussed in meetings but not formally incorporated into the care plan. The facility's policies required care plans to be updated promptly after significant changes in a resident's condition, but this was not done in this case. As a result, the resident's current needs and effective interventions were not accurately reflected in her care plan, potentially impacting the quality of care provided.
Deficient Wheelchair Safety Devices Lead to Fall Risks
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents. This deficiency was observed in two residents who were provided with fall interventions that included anti-rollback devices affixed to their wheelchairs. However, these devices were not functioning properly, as they were missing safety prongs, which are essential for preventing the wheelchairs from rolling backward when the residents attempted to stand. Resident #20, a male with severe cognitive impairment and under hospice care, was observed multiple times without a functioning anti-rollback device on his wheelchair. The left wheel safety prong was missing, posing a risk of the wheelchair rolling away if the resident attempted to rise. Staff members, including a CNA and an LVN, were unaware of how long the device had been faulty and acknowledged the potential fall risk due to the malfunctioning device. An occupational therapist confirmed the device's ineffectiveness and the associated risk. Resident #25, a female with Parkinson's disease and a history of falls, was also observed with a faulty anti-rollback device. The right wheel safety prong was missing, and the resident confirmed that the device had been non-functional for an extended period. Staff, including an RN and an occupational therapist, recognized the risk of falls due to the malfunctioning device but were unable to determine how long it had been faulty. The facility's administrator and DON acknowledged the issue, noting that only three residents required such devices, and two of them had ineffective ones.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as observed in the cases of two residents. Resident #43, who has Alzheimer's disease and severe cognitive impairment, was prescribed memantine to be administered twice daily at 08:00 AM and 05:00 PM. However, on the morning of 11/21/2024, the medication was administered 45 minutes late at 09:45 AM by LVN E. This delay in medication administration was noted in the facility's Medication Admin Audit Report. Resident #47, diagnosed with atherosclerotic heart disease and seizures, also experienced late medication administration. This resident was prescribed Valsartan and Levetiracetam to be taken twice daily at 08:00 AM and 05:00 PM, and Divalproex three times daily at 08:00 AM, 02:00 PM, and 08:00 PM. On 11/21/2024, LVN E administered all three medications at 09:54 AM, which was 54 minutes past the scheduled time. The resident's care plan emphasized the importance of administering medications as ordered due to her impaired cognitive function and potential for altered cardiac output. During an interview, LVN E acknowledged being late in administering medications and attributed the delay to her breakfast safety monitoring assignment, which concluded at 08:45 AM. She admitted to not communicating the potential for late medication administration to her supervisors. The facility's policy defines a medication error as any failure to meet the five rights of medication administration, including the right time, which is considered within one hour of the prescribed time. The DON and Administrator confirmed that late administration could risk residents not receiving the intended therapeutic effects of their medications.
Deficiency in Maintaining Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, specifically regarding the uploading of Out-of-Hospital Do Not Resuscitate (OOH DNR) order forms into their electronic medical records (EMR). For Resident #7, the signed OOH DNR order form was not properly uploaded, and instead, the form for another resident, Resident #38, was mistakenly included in her record. Resident #7's medical history included severe cognitive impairment and dementia, and her care plan indicated a DNR status. Resident #38 also did not have her signed OOH DNR order form uploaded into her EMR until after the issue was identified by a state agency surveyor. Her medical history showed moderate cognitive impairment and dementia, with a DNR order in place. Similarly, Resident #16's signed OOH DNR order form was missing from her EMR until the surveyor's intervention. Resident #16 had intact cognition and a history of neurological conditions, with a DNR order documented in her care plan. The Director of Nursing (DON) acknowledged the errors and stated that a system was in place to scan paper records into the EMR, but oversight was lacking. The DON and the Social Worker (SW) both highlighted the importance of accurate records for honoring residents' end-of-life wishes. The facility's policy required DNR orders to be signed and maintained in the resident's medical record, but this was not adhered to, leading to potential risks of incorrect care being provided.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8.0% due to 2 errors out of 25 opportunities. This involved a resident who was administered medications late. Specifically, an LVN administered metformin and metoprolol to a resident 30 minutes past the scheduled time of 08:00 AM, at 09:30 AM. The resident, who was admitted with diagnoses including diabetes mellitus and heart failure, was prescribed these medications to manage blood sugar levels and maintain a normal heart rhythm. The late administration was highlighted in red on the electronic medication administration record, indicating a delay. The LVN responsible for the late administration was assigned to medication duties for a third of the facility's residents and was also tasked with breakfast safety monitoring, which delayed the medication administration. The LVN did not communicate the potential for late administration to supervisors. During a joint interview, the Administrator and the DON confirmed that the late administration constituted a medication error, as it did not meet the 'right time' criterion, which requires administration within one hour of the prescribed time. The facility's policy mandates that medications be administered safely, timely, and as prescribed, without unnecessary interruptions.
Inadequate Hand Hygiene During Insulin Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during the care of a resident. LVN A did not perform hand hygiene between glove changes while conducting blood glucose monitoring and administering insulin to a resident. This oversight occurred despite the facility's policy and training requirements, which mandate hand hygiene before donning gloves and after glove removal. The resident involved was a female with a history of diabetes mellitus, requiring regular blood glucose monitoring and insulin administration. During the observation, LVN A prepared the necessary equipment for blood glucose monitoring and sanitized the glucometer while wearing gloves. However, LVN A failed to perform hand hygiene after discarding the gloves and before donning new ones. This pattern continued as LVN A administered insulin to the resident without performing hand hygiene between glove changes. In an interview, LVN A attributed the lapse to nervousness during observation. The Director of Nursing confirmed the importance of hand hygiene in preventing the transmission of illness among residents and staff, as outlined in the facility's hand hygiene policy and CDC guidelines.
Failure to Protect Resident from Abuse During Altercation
Penalty
Summary
The facility failed to protect a resident from abuse during a resident-to-resident altercation. On the date of the incident, a resident with severe cognitive impairment and significant visual impairment was involved in an altercation with another resident who had a history of aggressive and impulsive behaviors. The aggressive resident, who had been diagnosed with dementia and impulse disorder, struck the visually impaired resident, resulting in the latter falling to the floor. This incident was witnessed by another individual who reported that the visually impaired resident attempted to hit the aggressive resident first, leading to the altercation. The aggressive resident had a documented history of behavioral issues, including sexual and aggressive behaviors, entering other residents' rooms without permission, and taking food from others. Prior to the incident, there were multiple documented instances of the aggressive resident exhibiting inappropriate behaviors, such as flinging phlegm, yelling slurs, and attempting to physically harm other residents. Despite these documented behaviors, the facility failed to adequately prevent the altercation that occurred. The incident was reported to the local police, but the visually impaired resident chose not to press charges. The facility's records indicated that staff had been trained to recognize and defuse conflicts between residents, yet the altercation still occurred. The deficiency highlights the facility's failure to ensure the safety and protection of its residents from abuse, particularly in managing residents with known aggressive behaviors.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance with mechanical devices, leading to an accident involving a resident. An agency nurse aide attempted to transfer a resident using a mechanical lift by herself, contrary to the resident's care plan which required two staff members for transfers. During the transfer, the resident became agitated, causing the lift to tip over and resulting in the resident sustaining a head laceration and a left femur fracture. The resident involved was an elderly male with a history of dementia, contractures, bipolar disorder, and anxiety disorder. His cognitive assessment indicated he was cognitively unaware, and he required extensive assistance with two persons for transfers. Despite these requirements, the agency nurse aide proceeded with the transfer alone, leading to the accident. The facility's policy and the manufacturer's instructions recommended two assistants for mechanical lift transfers, although the equipment could be operated by one assistant based on professional evaluation. However, the facility's current Director of Nursing stated that two staff members were required for safety. The incident highlights a failure to adhere to the care plan and facility policy, resulting in harm to the resident.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not accurately describe the resident's need to have his coffee served in a mug with a tight lid to prevent spills. This oversight was identified through observations, interviews, and record reviews, revealing that the resident's care plan was incomplete and did not reflect his current needs for assistance with handling his coffee cup. The resident, who had diagnoses including heart failure, high blood pressure, swallowing difficulty, and Alzheimer's disease, experienced a decline in cognitive skills and required partial assistance with eating. Despite a previous incident where the resident spilled coffee on himself, resulting in redness to his thighs, the care plan was not updated to include necessary interventions such as staff assistance with handling the coffee cup and ensuring the lid was on tightly. Interviews with staff confirmed that the resident had a special mug with a lid to prevent spills, but this was not documented in the care plan. The deficiency was further highlighted by the fact that the care plan was resolved and not reactivated upon the resident's readmission to the facility. The Director of Nursing (DON) and the Minimum Data Set (MDS) Nurse acknowledged the oversight, noting that the care plan should have been reactivated to reflect the resident's current needs. The facility's policy on comprehensive person-centered care plans emphasized the importance of including measurable objectives and timetables to meet residents' needs, which was not adhered to in this case.
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.
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What surveyors actually found near you
We read the 477 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — 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 Boerne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town And Country Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 5 | 0 |
| Riverview Nursing & Rehabilitation | 1.1 mi | ★★★★★ | 2 | 0 |
| Cibolo Creek | 1.1 mi | ★★★★★ | 12 | 1 |
| Kendall House Wellness & Rehabilitation | 1.5 mi | ★★★★★ | 7 | 0 |
| Avir At Comfort | 16 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.