Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cibolo Creek during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, dementia, repeated falls, and impaired cognition was identified as an elopement risk but was found missing after leaving through an exit door near the private dining area. Staff later found her lying next to her wheelchair on an outdoor patio after she had been outside for about 30 minutes; she was assessed and noted to have a mild sunburn and to feel hot. Surveyors also observed that the alarm at the exit door was difficult to hear in the hallway and that no staff responded while the alarm sounded.
The facility was cited for failing to maintain current EMR/NAR screening documentation for 3 staff members employed longer than 1 year. The policy required screening for abuse, neglect, exploitation, and misappropriation of resident property, but HR could not provide proof that the staff had current EMR/NARs in their personnel files. The ADM stated HR was responsible for checking EMR/NARs upon hire and annually to ensure resident safety.
Kitchen staff failed to keep cold foods and the walk-in refrigerator within required temp ranges, failed to document temps for items such as milk and fruit cups before service, and served prepared foods without discard dates. Logs showed repeated walk-in refrigerator temps above 41°F, and staff observed cold items on the line at improper temps. The microwave was also observed with stains and particles inside.
Incomplete medical records and inaccurate MAR documentation: The facility failed to keep current care plan conference documentation for two residents and documented a diuretic-monitoring order incorrectly for another resident. One resident with CHF, HTN, and other chronic conditions had multiple MAR entries of “0” instead of the ordered “N” for diuretic monitoring, and both the RN and Interim DON acknowledged the entries did not match the MD order. Two other residents had care plan conference meetings listed on the schedule, but the conferences were not documented in the chart.
Walk-In Refrigerator Temperatures Out of Range: The kitchen walk-in refrigerator repeatedly ran above 41 degrees Fahrenheit across multiple temperature logs, with readings in the low to mid-40s and one at 47 degrees. The DM said the unit had been fluctuating, believed the freezer door was not closing properly, and noted the Maintenance Director had only addressed the freezer while the refrigerator remained out of range; the Maintenance Director later identified a stuck valve in the condensing unit affecting cooling.
A resident with dementia, severe cognitive impairment, and bilateral lower-extremity amputations had an outdated care plan that did not reflect his current transfer status. His MDS showed he was dependent for chair/bed-to-chair transfers, and staff confirmed he was transferred with a mechanical lift, but the comprehensive care plan had not been revised to match his current ADL needs after assessment review.
A resident experienced a significant change in mental status, becoming unresponsive and twitching, but the facility failed to notify the physician or family. The resident, who was cognitively intact and had chronic pain syndrome, was found lethargic by an LVN who did not take appropriate action. Other staff intervened later, but the delay in care placed the resident at risk.
A resident with chronic pain syndrome was found unresponsive and twitching, but the night shift nurse failed to assess or notify the physician, leading to a delay in care. The nurse did not check on the resident for several hours and relied on aides to search the room, finding a box of pills. The situation was only addressed when the morning shift nurse arrived, assessed the resident, and called 911 for emergency care.
A resident with a history of self-administering medications without notifying staff was found unresponsive after consuming a marijuana-laced brownie and having unauthorized medications at her bedside. Despite previous incidents, the facility's care plan did not address the resident's behaviors, and staff failed to provide adequate supervision and timely medical intervention, leading to an Immediate Jeopardy situation.
The facility failed to secure medications for two residents, leaving prescription shampoo, ointment, and eye drops unattended in their rooms. One resident had not been assessed for self-administration, while the other, although assessed, did not store medications in a locked box as required. Staff acknowledged the need for secure storage, but the facility's policies did not adequately address this, leading to the deficiency.
A facility failed to develop a comprehensive care plan for a resident who self-medicated with narcotics brought from outside. Despite being cognitively intact and having chronic pain, the resident's care plan lacked interventions for managing the behavior of bringing in medications. Staff interviews revealed the oversight, and the facility's policy on timely care plan development was not followed.
A resident with chronic pain syndrome was found unresponsive, but the facility failed to document the change in condition, assessments, or interventions, including the activation of EMS. Despite the resident's significant change in condition, there were no records of assessments or notifications, violating the facility's documentation policy.
A resident with chronic pain and mental health diagnoses experienced a significant change in condition, becoming unresponsive and exhibiting altered mental status. The nurse on duty failed to notify the physician and family or initiate timely emergency intervention, despite being aware of the resident's condition for several hours. The issue was only addressed when the oncoming nurse recognized the emergency and took appropriate action.
A resident with a history of chronic pain and recent orthopedic injuries was found unresponsive and twitching by an LVN, who failed to promptly assess, intervene, or notify medical personnel or family. The LVN did not conduct regular checks or initiate emergency protocols, resulting in delayed care until the next shift, when another LVN intervened and the resident was transferred to the hospital for altered mental status and hypoxemia.
A resident with a history of bringing unauthorized medications, including narcotics, into the facility was not adequately supervised, despite staff awareness of her behaviors and a late-night visitor. Staff failed to monitor the resident overnight, did not intervene after suspicious activity, and delayed emergency response when the resident was found unresponsive with unmarked pills at bedside. The resident was later hospitalized for altered mental status and hypoxemia after consuming a marijuana-laced brownie and possessing multiple medications.
Two residents were found with unsecured prescription and over-the-counter medications in their rooms, including prescription shampoo, ointments, and eye drops. One resident had not been assessed for self-administration and had no physician orders for the medications found, while the other, though approved for self-administration, did not keep medications locked as required. Staff interviews revealed inconsistent understanding and implementation of medication security policies, and facility policies lacked clear guidance on medication storage.
A resident with a history of chronic pain and multiple diagnoses brought in medications from outside sources and self-administered them without staff knowledge. Although these behaviors were documented by staff, the care plan was not updated to address the resident's actions related to polypharmacy or unauthorized medication use, contrary to facility policy and comprehensive assessment findings.
A resident with multiple medical conditions was found minimally responsive, and staff failed to document a complete assessment, SBAR communication, and timely interventions in the medical record. The lack of documentation included the resident's change in condition, discovery of pills at bedside, and the activation of EMS and hospital transfer, resulting in an incomplete record of care.
The facility failed to ensure call lights were within reach for three residents, all with severe cognitive impairments and requiring substantial assistance. Observations revealed call lights on the floor or out of reach, preventing residents from calling for help. Staff interviews confirmed the importance of accessible call lights for safety and fall prevention.
The facility failed to comply with food safety standards, as an employee was observed preparing food without a beard guard, contrary to policy. Additionally, improperly stored food items were found in the walk-in refrigerator and freezer, with containers unsealed and food exposed to potential contamination. The Dietary Manager confirmed these practices were against facility policy and FDA guidelines.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents. A Medication Aide did not sanitize a blood pressure cuff between residents, and two CNAs did not change gloves or sanitize hands after touching potentially contaminated surfaces while providing catheter care to a resident on Enhanced Barrier Precautions. These actions were contrary to the facility's infection control policies, despite staff having received training.
A resident with severe cognitive impairment and multiple medical conditions did not receive adequate privacy during wound care, as the ADON failed to fully close the privacy curtain, leaving the resident exposed. This was confirmed by the ADON and DON, despite staff having received training on resident rights.
A resident with multiple diagnoses, including type 2 diabetes, was inaccurately documented as receiving insulin in their MDS assessment. The resident was actually receiving Trulicity, a non-insulin medication, as per physician orders. The MDS nurse confirmed the error, acknowledging that Trulicity is not insulin and should not have been coded as such.
Resident Left Unsupervised Through Exit Door and Found Outdoors
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure adequate supervision to prevent accidents for one resident who was identified as an elopement risk. The resident had diagnoses including Alzheimer’s disease, repeated falls, and unspecified dementia, and her quarterly MDS reflected a BIMS score of 06, indicating moderately impaired cognition. Her care plan identified her as an elopement risk and wanderer related to impaired safety awareness and wandering aimlessly. On 8/28/2025, staff discovered the resident missing when a CNA attempted to give her a scheduled shower. A missing resident protocol was activated, and staff searched for her. She was later found by a PT on an outside patio, lying next to her wheelchair. Nursing staff assessed her, moved her back inside, and documented that she had a mild sunburn on her face and felt hot. The resident was reported to have been outside for approximately 30 minutes before being located. The investigation and interviews showed that the resident had exited through a door in the private dining room area. A dietician stated she had been in the private dining room and kitchen area shortly before the incident and heard an alarm going off at the door connecting the private dining room to the outdoor area, but she looked through the glass door, did not see anyone outside, and disabled the alarm. Survey observations later found that the exit alarm at the private dining area was functioning, but the alarm was difficult to hear in the hallway because of environmental noise, and no staff responded while the survey team remained in the area. The resident was unable to provide a meaningful interview due to cognitive decline, and staff stated she had not previously shown wandering behavior before the incident.
Missing Annual EMR/NAR Screening for Staff
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not maintain current EMR/NAR screening documentation for 3 of 7 staff members employed longer than 1 year: MA AG, FSM, and AD. The facility policy dated 2025 stated that potential employees, contracted temporary staff, students, volunteers, and consultants would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that documentation of the screening would be maintained. Record review showed MA AG was hired on 6/4/2012 and had a last EMR/NAR dated 1/16/2024, FSM was hired on 2/18/2022 and had a last EMR/NAR dated 6/27/2024, and AD was hired on 6/24/2019 and had a last EMR/NAR dated 6/26/2024. During interview, HR stated she ran reports for all staff in May 2025 but did not have documented proof that MA AG, FSM, and AD had current EMR/NARs in their personnel files. HR also stated she ran the EMR/NAR that day and the staff showed no concerns for employment. The ADM stated HR was responsible for ensuring staff EMR/NARs were checked upon hire and annually, and that the purpose of checking EMR/NARs was to ensure resident safety.
Kitchen Food Storage, Temperature Monitoring, and Date Marking Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. Record review of the walk-in refrigerator temperature logs for June, July, and August 2025 showed repeated temperatures above 41 degrees Fahrenheit on numerous days, including readings in the low 40s and one reading of 47 degrees Fahrenheit. The record review also reflected no action was taken after temperatures were above 41 degrees Fahrenheit during June and July 2025. During observation and interview, prepared foods were found without discard dates, including sliced cheese dated 08/25, chocolate pudding dated 09/02, and a peanut butter and jelly sandwich dated 09/01/25. Staff stated they sometimes put discard dates on food labels, but the Dietary Manager and Dietary Aide/Assistant also stated that food was generally thrown out after 3 days. The facility did not have a policy that reflected labeling food products with a discard date, even though the FDA Food Code requires ready-to-eat refrigerated time/temperature control for safety food held more than 24 hours to be clearly marked with a consume-or-discard date. The facility also failed to take temperatures for cold foods during meal service. Temperature logs for breakfast showed milk temperatures were not taken for multiple days, and during lunch service the temperature of fruit cups was not taken before service. Observations showed sour cream on the lunch line at 42 degrees Fahrenheit and fruit cups at 51 degrees Fahrenheit when temperatures were finally checked. Staff and management stated that the walk-in refrigerator had been fluctuating, that the freezer door may not have been closing properly, and that the refrigerator should not be above 41 degrees Fahrenheit. The kitchen microwave was also observed with brownish stains and particles inside, and staff acknowledged that if it were dirty it could cause cross contamination.
Incomplete medical records and inaccurate MAR documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 3 of 16 residents reviewed. For Resident #5, the record showed diagnoses including hypertension and congestive heart failure, with doctor’s orders for Furosemide 20 mg daily and Spironolactone 25 mg daily. The July MAR included a diuretics monitoring order requiring staff to document “N” every shift if none of the listed symptoms were observed, but RN AE documented “0” instead of “N” on multiple shifts across several days in July. During interview, RN AE stated that “0” meant no, but acknowledged she should have used “N” as ordered. The Interim DON also confirmed that staff entered “0” instead of “N” on the July MAR and stated staff should have used “N” because that was the physician’s order. The facility also did not have current care plan conference documentation for Resident #20. The resident’s record reflected admission and readmission diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, heart failure, diabetes II, aphasia, and hypertension. The quarterly MDS showed the resident was cognitively intact, used a wheelchair, had one-sided upper and lower impairment, and required assistance or dependence for several ADLs. The care plan in the record was dated 8/20/2020 and addressed falls risk, dependence for emotional, intellectual, physical, and social needs, ADL deficits, limited physical mobility, and refusal of some showers. The record did not document a care plan conference on 11/5/2024, although the care plan conference meeting schedule provided by ADM/SW listed meetings on 2/4/2025 and 5/6/2025. Resident #38 also did not have current care plan conference documentation. The resident’s record reflected diagnoses including osteoarthritis, COPD, chronic kidney disease, mild cognitive impairment, and unsteady gait. The quarterly MDS showed the resident was cognitively intact, ambulated with a walker, was independent with several ADLs, had mild cognitive impairment, and was on pain management. The care plan dated 6/4/2025 addressed infection risk, dependence on staff for emotional, intellectual, physical, and social needs, ADL self-care deficits related to fatigue and impaired balance, a potential communication problem related to mild hearing loss, and falls risk. The record did not document a care plan conference on 5/23/2025, although the care plan conference meeting schedule provided by ADM/SW listed a meeting on 5/21/2025. During interview, the ADM/SW stated she was responsible for care plan conferences and acknowledged that care plan conferences for Residents #20 and #38 were not documented.
Walk-In Refrigerator Temperatures Out of Range
Penalty
Summary
The facility failed to maintain the walk-in refrigerator in the kitchen in safe operating condition. Record review of the Refrigerator/Freezer Temperature Log for June, July, and August 2025 showed repeated temperatures above 41 degrees Fahrenheit on numerous days, including readings in the low to mid-40s and one reading of 47 degrees Fahrenheit. The report identified this as the only walk-in refrigerator reviewed for essential equipment, and the temperature logs showed ongoing fluctuations rather than isolated occurrences. During interviews, the Dietary Manager stated the walk-in refrigerator had been fluctuating and believed the issue was related to the freezer door not closing all the way. She stated the refrigerator should not be above 41 degrees Fahrenheit and that the only corrective action taken was the Maintenance Director coming to fix the freezer. The Maintenance Director later stated he had not known about the temperature problems until the day before one interview, and another interview with him identified a stuck valve in the condensing unit outside that was affecting the refrigerator's cooling. The former Dietary Manager stated the temperatures were sometimes out of range, that maintenance had been told, and that the walk-in refrigerator needed to remain within an appropriate temperature to prevent spoiled food, rotten food, or cross contamination.
Care Plan Not Updated for Transfer Needs
Penalty
Summary
The facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly MDS assessments, for one resident. Resident #9 was a male with dementia, muscle weakness, an acquired absence of the left leg above the knee, and an acquired absence of the right leg below the knee. His quarterly MDS assessment dated 08/22/2025 showed a BIMS score of 06 out of 15, indicating severely impaired cognition, and documented that he was dependent for chair/bed-to-chair transfers and had no falls since admission or the prior assessment. The resident’s comprehensive care plan, last reviewed on 04/25/25, stated that he had an ADL self-care performance deficit related to poor cognitive deficit, bilateral BKA, and decreased function, with a revision date listed as 05/11/2029. Observation on 09/02/2025 at 12:13 PM showed the resident with a sling for a mechanical lift. Staff interviews confirmed that he was transferred with a mechanical lift and that the care plan should reflect this current transfer method. The MDS RN stated the resident fluctuated from extensive assistance to dependent assistance but was now dependent for transfers, and the Interim DON stated the care plan should be updated to reflect that he needed to be transferred by a mechanical lift.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. This deficiency was identified for a resident who was found sleepier than usual on one day and unresponsive with a significant alteration in mental status the following morning. Despite these changes, the facility did not notify the resident's physician or family, which led to a delay in care. The resident, who had a history of chronic pain syndrome and was cognitively intact, was found by a nurse to be lethargic and unable to fully arouse. The nurse, LVN A, did not notify the physician or the family about the resident's condition and instead reported the situation to the oncoming shift. The resident was later found unresponsive and twitching, with a significant alteration in mental status, and was eventually treated for altered mental status at the hospital. Interviews with staff revealed that LVN A was aware of the resident's condition but failed to take appropriate action, such as notifying the physician or calling emergency services. Other staff members, including LVN B and nurse aides, expressed concern about the resident's condition and took steps to address the situation, but only after a significant delay. The facility's failure to act promptly placed the resident at risk for serious harm.
Failure to Provide Timely Care for Unresponsive Resident
Penalty
Summary
The facility failed to provide timely and appropriate care to a resident who was found unresponsive and twitching. On the night of the incident, the resident, who had a history of chronic pain syndrome and was cognitively intact, was not properly monitored by the night shift nurse, LVN A. Despite being informed by aides that the resident was lethargic and unresponsive, LVN A did not perform a thorough assessment or notify the physician or family. Instead, she waited for the next shift to arrive, resulting in a delay in care. LVN A's inaction continued throughout the night as she failed to check on the resident between 11:00 p.m. and 5:00 a.m., despite the facility's policy to check on residents every two hours. When she finally entered the resident's room at 5:30 a.m., she found the resident unresponsive but did not take immediate action. Instead, she relied on the aides to search the room and found a small box of pills, which she did not report or act upon. LVN A's failure to assess the resident's condition and notify the appropriate parties led to a significant delay in the resident receiving necessary medical attention. The situation was only addressed when LVN B arrived for the morning shift and immediately assessed the resident, recognizing the severity of the situation. LVN B called 911 and ensured the resident received emergency medical care. The delay in care and lack of appropriate response from LVN A was identified as a deficiency in the facility's care practices, highlighting a failure to adhere to professional standards and the resident's care plan.
Inadequate Supervision and Medication Mismanagement
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a history of bringing medications, including narcotics, into the facility without notifying staff. The resident consumed a marijuana-laced brownie and was found with Ambien and trazadone in an unmarked container at her bedside. On the night of the incident, staff failed to check on the resident between 11:00 p.m. and 5:00 a.m., despite an unknown visitor being seen in her room. The resident was later found unresponsive and twitching, leading to an Immediate Jeopardy situation. The resident had a history of chronic pain and was under the care of a pain specialist. She had been self-administering medications, including morphine, without notifying the facility staff. Despite previous incidents where the resident was found with unauthorized medications, the facility's care plan did not address the resident's behaviors of polypharmacy or having medications in her room without staff knowledge. The facility's staff, including a nurse and nurse aides, failed to respond appropriately to the resident's change in condition, delaying necessary medical intervention. Interviews with staff revealed a lack of communication and appropriate action in response to the resident's condition. The nurse on duty did not notify the physician or call 911 when the resident was found unresponsive, and there was confusion among the aides about their responsibilities. The facility's administrator acknowledged the failure to provide adequate supervision and the presence of unauthorized medications in the resident's room, which contributed to the resident's altered mental status and subsequent hospitalization.
Failure to Secure Medications for Residents
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, resulting in unsecured medications being left in their rooms. For Resident #2, clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin ointment were found unsecured on the dresser in the resident's room. The resident, who was observed in bed and did not respond to questions about the medications, had not been assessed for self-administration of medication, and there were no physician orders for these medications. LVN B confirmed that the shampoo was a prescription and stated that the resident could not keep these medications in the room. For Resident #3, two bottles of Simbrinza ophthalmic suspension and five medication cups with an unknown ointment were left unsecured on the over-bed table while the resident was not present. Although Resident #3 had been assessed as capable of self-administering medications, the medications were supposed to be kept in a lockbox, which was found unlocked with the key in the lock. CNA D and LVN P both acknowledged that medications should be secured, especially since some residents might confuse them with candy. Despite this, the medications were left unattended in the room. The facility's policies on medication administration and self-administration did not adequately address the storage of medications, contributing to the oversight. The lack of secure storage for medications poses a risk of inaccurate or inappropriate administration, particularly in a setting where residents may wander and potentially access unsecured medications.
Failure to Address Self-Medication Behavior in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included addressing behaviors related to self-medicating with medications brought from outside the facility. The resident, who was cognitively intact and had a history of chronic pain, was found to have been self-administering morphine and other narcotics obtained from an outside pharmacy without informing the facility staff. Despite being followed by a pain specialist, the resident's care plan did not include interventions to manage the behavior of bringing in medications from home or other sources. Interviews with facility staff revealed that the care plan did not address the resident's behavior of bringing in medications, and no interventions were put in place to manage this issue. The MDS Coordinator acknowledged that the behavior should have been included in the care plan to ensure all staff were aware and could manage the resident's care appropriately. The Regional RN also noted that the behavior should have been documented in the care plan to ensure comprehensive care. The facility's policy required that comprehensive care plans be developed within seven days of the MDS assessment, but this was not adhered to in this case.
Failure to Document Resident's Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a deficiency in documentation. The resident, who was cognitively intact with a history of chronic pain syndrome, was found unresponsive by a nurse (LVN A) on the morning of 11/19/2024. Despite the resident's significant change in condition, there were no documented assessments, notifications, or interventions recorded in the medical records, such as an SBAR assessment or the activation of emergency services. Interviews revealed that LVN A was aware of the resident's lethargy the previous night but did not document any assessments or notify the physician. When LVN B arrived for the morning shift, he found the resident in a concerning state and instructed LVN A to call 911. However, LVN A had not documented any of these events or the subsequent transfer to the hospital. The facility's policy required timely and accurate documentation of all assessments and changes in condition, which was not adhered to in this case. The lack of documentation could result in an incomplete view of the resident's care and services. The facility's policy emphasized the importance of documenting the entire chain of events, including assessments, vitals, and notifications, to ensure continuity of care. The failure to document these critical events and interventions represents a significant lapse in maintaining professional standards for medical records.
Failure to Notify Physician and Family of Significant Change in Resident Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician and family following a significant change in the resident's condition. The resident, who had a history of chronic pain syndrome, depression, anxiety disorder, and was cognitively intact, was found to be sleepier than usual on one evening and then unresponsive with altered mental status the following morning. Despite these acute changes, the nurse on duty did not notify the physician or the resident's family, nor did she initiate emergency medical services in a timely manner. Multiple staff interviews and record reviews revealed that the nurse was aware of the resident's unresponsiveness and abnormal behavior for several hours but did not take appropriate action. Nurse aides reported the resident was not waking up, was twitching, and had a bag of pills at her bedside, but the nurse did not assess vital signs promptly or notify medical personnel. The nurse admitted to being tired and waiting for the next shift to take over, and she did not follow established protocols for change of condition notifications. The delay in care was further corroborated by statements from other staff, who expressed concern over the nurse's lack of response and failure to act according to her training. The resident was eventually sent to the hospital by the oncoming nurse, who immediately recognized the severity of the situation, notified the physician and family, and called EMS. Hospital records confirmed the resident was treated for altered mental status and hypoxemia, and facility documentation showed that the required notifications and interventions were not made in a timely manner.
Failure to Respond to Resident's Acute Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of chronic pain syndrome, depression, anxiety disorder, and recent orthopedic injuries was found unresponsive and twitching in the early morning hours by an LVN. The resident, who was normally alert and oriented, was discovered to have a significant change in mental status, including lethargy, inability to fully arouse, and incomprehensible speech. Despite these acute symptoms, the LVN did not immediately assess or intervene appropriately, nor did she notify the physician, call 911, or inform the resident's family. The LVN also failed to conduct regular checks on the resident between 11:00 p.m. and 5:00 a.m., citing the resident's preference not to be disturbed, and instead relied on aides who were not qualified to provide clinical assessment or intervention. Multiple staff statements and interviews confirmed that the LVN was made aware of the resident's unresponsiveness by aides but did not take timely action. The LVN delayed obtaining vital signs and did not perform a thorough assessment or initiate emergency protocols. When the oncoming LVN arrived for the next shift, he immediately recognized the severity of the resident's condition, performed an assessment, obtained vital signs, and ensured that 911 was called. The resident was subsequently transferred to the hospital, where she was treated for altered mental status and hypoxemia, and received Narcan for suspected opioid overdose, with some improvement noted. Throughout the incident, documentation and interviews revealed that the LVN failed to follow professional standards of practice, the resident's care plan, and facility policy regarding timely assessment and intervention for a change in condition. There was no evidence that the physician or family were notified in a timely manner, and the LVN did not document appropriate actions or interventions. The inaction and lack of appropriate response to the resident's acute change in condition constituted a failure to provide care and treatment in accordance with orders, resident preferences, and established protocols.
Failure to Supervise Resident with History of Unauthorized Medication Use
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent accident hazards for a resident with a history of bringing in multiple medications, including narcotics, without staff knowledge. The resident, who was cognitively intact and had diagnoses including chronic pain syndrome, depression, and anxiety, was known to self-administer medications obtained from outside providers and pharmacies. Despite previous incidents where staff discovered unapproved medications in the resident's room and provided education, the care plan did not address the resident's behaviors related to polypharmacy or unsupervised medication possession. On the night in question, staff observed an unknown visitor entering and leaving the resident's room with a package, but did not intervene or monitor the situation further. The resident was not checked on between 11:00 p.m. and 5:00 a.m., despite staff awareness of the visitor and the resident's history. At 5:30 a.m., the resident was found unresponsive and twitching, with a container of mixed, unmarked pills at her bedside. Staff delayed notifying the physician and calling emergency services, and there was confusion among staff regarding who was responsible for monitoring the resident and responding to her change in condition. Interviews and record reviews revealed that staff failed to follow up on reports of suspicious activity, did not conduct timely assessments, and did not ensure the resident's safety despite clear risk factors. The resident was ultimately found to have consumed a marijuana-laced brownie and had opioids and other medications in her system, resulting in hospitalization for altered mental status and hypoxemia. The facility's lack of supervision and failure to implement effective interventions placed the resident at risk for serious harm.
Failure to Secure Resident Medications and Ensure Proper Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that medications were properly secured for two residents. For one resident, clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin ointment were found unsecured on the resident's dresser while the resident was in bed and unattended by staff. The resident did not respond to questions about the medications, and it was unclear if he was cognitively intact. There were no physician orders for these medications, and the resident had not been assessed for self-administration of medication. A nurse confirmed that these medications should not have been kept in the resident's room and removed them after the observation. For another resident, two bottles of prescription Simbrinza ophthalmic suspension and five medication cups containing an unknown white ointment were observed on the over-bed table while the resident was not present in the room. Although this resident had been assessed as cognitively intact and approved for self-administration of certain medications, the care plan specified that medications should be kept in a lockbox. During the observation, the lockbox was present but unlocked, and the key was left in the lock. Staff interviews revealed confusion about which residents were permitted to self-administer medications and how medications should be stored. The nurse acknowledged that medications should be locked up when the resident was not in the room, but left the medications unsecured after the observation. Facility policies reviewed did not adequately address the storage of medications or provide clear guidance for self-administration. The policy on self-administration referenced the need for residents to store medications safely and securely, but this was not consistently implemented. Staff interviews indicated a lack of awareness and inconsistent practices regarding medication security, contributing to the deficiencies observed.
Failure to Address Self-Medication Behaviors in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited behaviors of bringing in medications from home, from other providers, and from visitors, and self-medicating without informing staff. Despite documentation in provider and nursing progress notes that the resident had obtained and self-administered narcotic pain medications from outside sources, these behaviors were not addressed in the resident's care plan. The care plan only included interventions for chronic pain management as per orders, without any mention of the resident's actions related to polypharmacy or unauthorized medication use. Interviews with facility staff, including the MDS Coordinator and Regional RN, confirmed that the care plan did not reflect the resident's behaviors, and that this omission was not recognized until after multiple incidents had occurred. The facility's own policy required that comprehensive care plans address all factors identified by the interdisciplinary team or in accordance with resident preferences, but the care plan was not updated to include interventions for the resident's medication-related behaviors, despite staff awareness and documentation of these incidents.
Failure to Document Change of Condition and Interventions in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced a significant change in condition. The resident, who had a history of chronic pain syndrome, depression, anxiety disorder, and recent orthopedic injuries, was found by staff to be lethargic and minimally responsive in the early morning hours. Despite these findings, there was no documentation in the medical record of a thorough assessment, SBAR (Situation, Background, Assessment, Recommendation) communication, or timely notification and activation of emergency services. The nurse on duty noted the resident's unresponsiveness and the discovery of unidentified pills in the room but did not document further assessments or interventions in the medical record. Interviews revealed that the nurse on the previous shift was informed by aides of the resident's change in condition but did not notify the physician or transfer the resident to the hospital. The oncoming nurse, upon learning of the situation, immediately assessed the resident, found her to be very lethargic, and instructed the previous nurse to call 911. However, neither nurse documented the full chain of events, assessments, or notifications in the resident's medical record as required by facility policy and professional standards. Facility policy requires that all assessments, observations, and services provided be documented in a timely, factual, and complete manner. In this case, the lack of documentation regarding the resident's change in condition, the discovery of medication at bedside, and the subsequent transfer to the hospital resulted in an incomplete medical record. This failure was confirmed through interviews with staff and review of the resident's records, which lacked the necessary details to provide an accurate and comprehensive account of the care provided during the incident.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, which could prevent them from calling for help when needed. Resident #19, who has severe cognitive impairment and requires substantial assistance for mobility and is at high risk for falls, was observed with her call light on the floor under her bed. During an interview, a medical assistant confirmed that the call light should be within reach and placed it back on the bed. Resident #21, also with severe cognitive impairment and requiring substantial assistance, was observed with her call light on the floor next to her bed. A CNA acknowledged that the call light should have been within reach and placed it under the resident's hand. Later, the call light was again found on the floor, and a medical assistant reiterated the importance of having the call light accessible for safety. Resident #49, with severe cognitive impairment and requiring maximal assistance, was observed with her call light hanging behind her and later on the floor. The resident stated she could not reach it, and a CNA confirmed the importance of having the call light within reach. The ADON also noted the call light was inaccessible and placed it across the resident. The DON emphasized that call lights are part of fall prevention measures and should always be within reach.
Food Safety Violations in Kitchen and Storage Areas
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. An employee, identified as [NAME] I, was seen preparing food without wearing a moustache or beard guard, despite having facial hair. This was against the facility's policy, which mandates the use of hair restraints to prevent hair from contacting food. The Dietary Manager confirmed that it was the policy for kitchen staff to use such restraints, but [NAME] I stated he had never been instructed to wear them and was unaware of their availability. This lack of compliance with the facility's policy and the U.S. FDA Food Code could potentially expose food to contamination. Additionally, the facility's walk-in refrigerator and freezer were found to contain improperly stored food items. In the refrigerator, a cardboard container of lunchmeat was wet and deteriorating, and a container of butter was uncovered, with loose pieces of butter exposed. In the freezer, three unsealed cardboard containers held tater tots, vegetable medley, and cinnamon roll pinwheels, all in unsealed plastic bags, leaving the food exposed to air. The Dietary Manager acknowledged that these items should have been stored in sealed containers to prevent contamination and freezer burn. These practices were not in line with the facility's policy or the U.S. FDA Food Code, which requires food to be stored in a manner that protects it from contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a Medication Aide did not sanitize a blood pressure cuff between its use on two residents. This oversight was confirmed by the Medication Aide, who acknowledged forgetting to use a disinfecting wipe to prevent cross-contamination, despite having received infection control training within the year. The Director of Nursing (DON) also confirmed that the blood pressure cuff should have been sanitized between uses, in accordance with the facility's policy on cleaning and disinfection of resident-care equipment. In the second incident, two CNAs providing catheter care to a resident on Enhanced Barrier Precautions failed to change their gloves or sanitize their hands after touching the privacy curtain and the environment outside the resident's room. The CNAs admitted to not sanitizing their hands before donning gloves and gowns and acknowledged that they should have changed gloves and sanitized their hands after touching potentially contaminated surfaces. The DON confirmed that the environment outside the resident's room was considered contaminated and that proper hand hygiene should have been practiced. Both incidents highlight lapses in adherence to the facility's infection control policies, which require multiple-resident use equipment to be disinfected after each use and staff to perform hand hygiene when indicated. Despite the facility providing infection control training multiple times a year and conducting annual skills checks, these deficiencies were observed, indicating a need for improved compliance with established protocols.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during wound care, as observed by surveyors. The Assistant Director of Nursing (ADON) did not completely close the privacy curtain while providing wound care to a resident, leaving the resident exposed and visible from the room's door. This lapse in privacy was further compromised when a hospice services nurse entered the room and could see the resident receiving care. The resident involved had a history of severe cognitive impairment, osteomyelitis, osteoporosis, and a stage 4 pressure ulcer, requiring extensive assistance with activities of daily living. Interviews with the ADON and the Director of Nursing (DON) confirmed that the privacy curtain was not fully closed during the care, which was against the facility's policy on maintaining resident dignity. Both the ADON and DON acknowledged that staff had received training on resident rights within the year, and the DON stated that privacy must be provided during nursing care. The facility's policy emphasized the importance of maintaining resident privacy, which was not adhered to in this instance.
Inaccurate Assessment of Resident's Medication
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically for a resident who was incorrectly documented as receiving an insulin injection. The resident, who had diagnoses including dementia, hemiplegia, Alpers disease, and type 2 diabetes mellitus, was actually receiving Trulicity, a non-insulin medication, as per physician orders. The medication administration record confirmed that the resident received Trulicity as ordered, but the significant change Minimum Data Set (MDS) inaccurately recorded the resident as having received insulin. During an interview, the MDS nurse confirmed the error, acknowledging that Trulicity is not an insulin and should not have been coded as such. The nurse had access to the Resident Assessment Instrument (RAI) for reference but still made the coding error. This inaccuracy in the resident's assessment could potentially place residents at risk for inadequate care and services due to the incorrect documentation of their medical treatment.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 530 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Riverview Nursing & Rehabilitation | 0.1 mi | ★★★★★ | 2 | 0 |
| Care Choice Of Boerne | 1.1 mi | ★★★★★ | 17 | 0 |
| Town And Country Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 5 | 0 |
| Kendall House Wellness & Rehabilitation | 1.4 mi | ★★★★★ | 7 | 0 |
| Estates At Shavano Park | 16.8 mi | ★★★★★ | 20 | 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.