Average — CMS composite of the measures below.
The next survey window likely opens 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 Kendall House Wellness & Rehabilitation during CMS and state inspections, most recent first.
Food storage practices were deficient when sanitation buckets were observed near food items in the kitchen, including corn meal and bananas, and staff acknowledged the buckets should not be stored near food. The facility also failed to ensure a resident's personal refrigerator was kept at a safe temperature for food storage; the resident had dementia and hospice care, and the RP stated there was no thermometer in the refrigerator and he did not know the proper temperature for safe food storage.
Failure to Document and Resolve Resident Grievance: A resident with metastatic cancer, moderate cognitive impairment, incontinence, and total ADL dependence was reportedly served breakfast while soiled from a bowel movement. Her representative complained to an RN about the resident’s condition and care, but the RN did not document the grievance, and the grievance log contained no record of the complaint. The representative reported no resolution and said she was unaware of the facility’s grievance policy.
A resident with depression and GAD had orders for Buspar and Cymbalta, but the telephone consents for both psychotropics were documented with only one nurse signature. Staff interviews showed the LPN who obtained the consents did not have a second nurse witness, while the DON and ADON acknowledged issues with psychotropic consent documentation and the facility policy required verbal approval with two licensed nurses witnessing.
Medication administration errors resulted in a 7.41% error rate when an RN crushed an extended-release antidepressant and gave a lower-than-ordered dose of folic acid to a resident with stroke, depression, mild cognitive impairment, and a swallowing disorder. The pharmacy label stated the desvenlafaxine tablet should be swallowed whole and not crushed, while the physician order called for folic acid 5 mg but 1 mg was given. The DON confirmed the errors and the facility policy required medications to be given according to the order, including the right dosage and method of administration.
Crushed extended-release antidepressant administered to a resident. An RN crushed and gave desvenlafaxine, even though the order and pharmacy label stated it was an ER tablet to swallow whole and not crush. The resident had a stroke history, depression, mild cognitive impairment, and difficulty swallowing medications. The NP and DON both stated the medication should not have been crushed.
A facility failed to update a resident's care plan after a fall, despite the resident's severe cognitive impairment and high fall risk. The care plan did not reflect increased monitoring or the 24-hour care provided by the family. The DON acknowledged the oversight, which was against the facility's policy requiring care plans to be based on comprehensive assessments.
A resident with cognitive impairments and physical limitations suffered burns after being served hot coffee, despite care plan instructions prohibiting hot beverages without supervision. The facility failed to ensure proper supervision and adherence to dietary restrictions, resulting in the resident spilling coffee and sustaining burns.
The facility failed to implement baseline care plans addressing fall risks for four residents, despite their high-risk assessments. Residents with conditions like Parkinson's disease and mobility issues did not have fall interventions in their care plans. Staff interviews revealed a lack of awareness and communication about fall interventions, with standard precautions applied universally rather than tailored to individual needs. This practice did not comply with the facility's policy requiring care plans within 48 hours of admission.
A resident with hypertension was not administered Midodrine according to physician's orders, which required holding the medication if systolic blood pressure exceeded 110. Despite this, the medication was given multiple times when the resident's blood pressure was above the threshold. Nursing staff were unaware of the updated prescription parameters, leading to this oversight.
A resident's right to a safe and comfortable environment was compromised due to a malfunctioning bathroom door that was difficult to operate, posing a risk of injury. Despite being reported, the issue persisted for several days, with maintenance efforts proving insufficient. The resident, who had a history of falls, and her family expressed concerns about the door's condition, which was confirmed by facility staff.
The facility failed to prepare pureed food by following the prescribed recipes, specifically for pureed baked fish and carrots. A staff member admitted to not using the written measurements, opting instead to eyeball the quantities, which deviated from the facility's policy. This practice could affect residents on a pureed diet, risking inadequate nutrition.
Food Storage and Refrigerator Temperature Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 3 residents' refrigerators. During observation on 01/22/26 at 10:41 AM, a bag of yellow corn meal was seen next to two sanitation buckets, and the CDM stated the corn meal should not be next to the buckets. In another kitchen area, a different sanitation bucket was observed next to a carton of bananas, and the CDM stated the bucket should not be near the bananas. Later, the FSS stated she would not store sanitizing buckets near foods to prevent the hand sanitizer from mixing with the food. The facility also failed to ensure foods in Resident #8's refrigerator were kept at a temperature for safe food consumption. Resident #8 was admitted with dementia, had a BIMS score of 12 out of 15 indicating moderately impaired cognition, and had a care plan noting hospice care related to dementia. The ADON stated the facility did not have a policy for checking residents' personal refrigerators and that families checked them. The RD stated families oversaw personal refrigerators and were responsible for thermometers and checking temperatures. During interview and observation, Resident #8 was unable to contribute, and the RP stated there was no thermometer in the refrigerator and he was not aware of the temperature needed for safe food storage.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure residents had the right to voice grievances regarding care and treatment, staff behavior, and other concerns, as shown by the handling of Resident #23’s representative’s complaint. Resident #23 was admitted with metastatic lung cancer involving the brain, spine, liver, and bones, had a BIMS score of 9 indicating moderate cognitive impairment, was incontinent of bowel and bladder, required staff assistance with all ADLs, and had several wounds including on the buttocks. Her care plan noted impaired bed mobility and chronic pain related to osteoarthritis and cancer. According to the representative, on 1/17/2026 Resident #23 was in bed, soiled from a bowel movement, and was served breakfast before being cleaned. The representative complained to RN D and stated she was upset that the resident was served a meal while soiled, but she never received a resolution and was unaware of the facility’s grievance policy. RN D recalled the complaint but did not document it, stating she did not do so because the resident was later provided ADL care. The facility’s grievance log for November 2025 through January 2026 contained no grievance for Resident #23, and the DON stated RN D should have documented the complaint.
Missing second nurse witness on psychotropic telephone consents
Penalty
Summary
Pharmaceutical services were not provided in a way that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident reviewed for pharmacy services. The resident was admitted with diagnoses including depression and generalized anxiety disorder, and the quarterly MDS reflected a BIMS score of 13 out of 15, indicating intact cognition. The resident’s order summary included Buspirone HCl 5 mg twice daily for anxiety and Duloxetine HCl 60 mg daily for anxiety/depression. Record review showed the resident’s telephone consent for Cymbalta and the telephone consent for Buspar were both documented with only LVN A’s signature. During interview, LVN A stated she never had a second nurse signature as a witness for telephone consents for psychotropics and said the ADON oversaw completion of these consents. The DON stated there were psychotropic consents without two nurse signatures and that she had been working on updating them, while the ADON stated he oversaw that two nurses signed telephone consents for psychotropics and that it was important for validation. The facility policy stated it would utilize either signed consent or verbal approval with two licensed nurses witnessing.
Medication Administration Errors With Crushed Extended-Release Drug and Incorrect Dose
Penalty
Summary
Medication administration errors resulted in a 7.41% error rate for 1 of 6 residents reviewed, with 2 errors identified during 27 observations. RN B administered crushed desvenlafaxine 50 mg to Resident #30 even though the medication was prescribed as an extended-release 24-hour tablet and the pharmacy label stated it should be swallowed whole and not crushed. RN B also administered folic acid 1 mg to Resident #30 when the physician order prescribed folic acid 5 mg once daily. Resident #30 was admitted on 12/31/2025 with diagnoses including stroke, depression, and muscle weakness. Her admission MDS assessment dated 1/7/2026 documented a BIMS score of 10 out of 15, indicating mild cognitive impairment, and noted that she usually made herself understood and usually understood others. The assessment also identified a swallowing disorder and difficulty swallowing medications. Her care plan included antidepressant therapy with desvenlafaxine and directed that medications be administered as ordered by the physician. During the observed medication pass, RN B prepared crushed medications for Resident #30, including folic acid and desvenlafaxine, and administered them to the resident. The facility’s physician orders allowed some medications to be crushed except specially coated or prolonged-action medications, and the desvenlafaxine order specifically called for a 50 mg extended-release tablet. The DON stated that RN B should not have crushed the desvenlafaxine and should have administered 5 mg of folic acid, and the facility policy required medications to be administered in accordance with the orders and the right dosage and method of administration.
Crushed extended-release antidepressant administered to resident
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 1 of 6 residents reviewed, involving Resident #30. On 1/22/2026, RN B administered desvenlafaxine 50 mg by crushing the tablet before giving it to the resident. Desvenlafaxine was ordered as an extended-release 24-hour tablet, and the pharmacy label stated to swallow whole and not to chew or crush it. The resident’s physician orders also allowed some medications to be crushed except specially coated or prolonged-action medications, which included this medication. Resident #30 was admitted on 12/31/2025 with diagnoses including stroke, depression, and muscle weakness. Her MDS assessment documented a BIMS score of 10 out of 15, mild cognitive impairment, and a swallowing disorder with difficulty swallowing medications. During observation, RN B prepared the resident’s crushed medications, including desvenlafaxine, and administered them to the resident. The NP stated desvenlafaxine should not be crushed because it is extended-release and should be dispersed evenly over time, and the DON stated RN B should not have crushed the medication.
Failure to Update Care Plan After Resident Fall
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 needs. The deficiency was identified for a resident who had a severe cognitive impairment and was at high risk for falls. Despite the resident experiencing a fall, the facility did not update the care plan to reflect the incident or include strategies to prevent further falls. The resident's care plan, dated prior to the fall, did not incorporate the increased monitoring or the 24-hour one-to-one care provided by the family after the fall. The Director of Nursing (DON) acknowledged the oversight in not updating the care plan following the resident's fall. The DON admitted that it was their responsibility to develop and update the care plan after reviewing each actual fall, but they failed to do so. The facility's policy required that care plans be based on comprehensive assessments and developed by an interdisciplinary team, but this was not adhered to in this case. The lack of an updated care plan could potentially lead to inadequate care for the resident.
Inadequate Supervision Leads to Resident Burns from Hot Coffee
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, resulting in the resident sustaining burns from spilling hot coffee. The resident, who had a history of stroke, hemiplegia, dysphagia, and dementia, was documented as requiring substantial assistance with eating and was not to have any hot beverages per the resident representative's request. Despite this, the resident was served hot coffee, leading to a first-degree burn on the hand and a second-degree burn on the thigh. The resident's care plan and dietary instructions clearly indicated that the resident should not receive hot beverages unless supervised, and lids were to be placed on all drinks. However, observations and interviews revealed inconsistencies in the implementation of these precautions. The resident was observed with a Styrofoam cup of coffee, and staff interviews indicated a lack of awareness and adherence to the resident's dietary restrictions and supervision needs. Interviews with facility staff, including the Administrator, DON, and dietary personnel, highlighted a breakdown in communication and protocol adherence. The facility's coffee machines were not recalibrated to a safe temperature, and there was confusion about the serving of hot beverages. Despite the resident representative's explicit instructions, the resident was still exposed to hot liquids, leading to the incident.
Failure to Implement Baseline Care Plans for Fall Risk
Penalty
Summary
The facility failed to develop and implement baseline care plans for four residents, which included necessary interventions for fall risks. Resident #15, who had Parkinson's disease and other mobility issues, was identified as a high risk for falls, but her care plan did not include any interventions for this risk. Similarly, Resident #27, who was admitted with a high fall risk, did not have fall interventions included in her care plan until several weeks after admission, despite being assessed as high risk upon entry. Resident #80, with a cardiac pacemaker and requiring assistance with personal care, also had a high fall risk assessment, yet her care plan lacked any focus or interventions related to falls. Resident #10, who had multiple diagnoses including muscle weakness and mobility issues, was assessed as high risk for falls, but his care plan did not address this risk. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not adhered to for these residents. Interviews with facility staff revealed a lack of awareness and communication regarding fall interventions. CNAs were not fully informed about fall interventions, and standard fall precautions were only implemented universally without specific interventions for high-risk residents. The Director of Nursing acknowledged the importance of having fall interventions in care plans but stated that specific interventions were typically added only after a fall occurred in the facility. This practice did not align with the facility's policy or professional standards of care, potentially placing residents at risk of inadequate care.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident. Specifically, the facility did not administer Midodrine according to the physician's orders, which required the medication to be held if the resident's systolic blood pressure was greater than 110. Despite this order, the medication was administered on multiple occasions when the resident's systolic blood pressure exceeded the specified threshold. This oversight was identified through a review of the resident's Medication Administration Record (MAR) for August and September 2024, which documented several instances where the medication was not held as required. The resident involved had a history of hypertension and was initially prescribed Midodrine without blood pressure parameters due to consistently low blood pressure. However, the prescription was later updated to include parameters to hold the medication if the systolic blood pressure was above 110. Interviews with the nursing staff revealed a lack of awareness regarding the updated prescription parameters, leading to the continued administration of Midodrine despite the resident's elevated blood pressure readings. The facility's policy on administering medications emphasized the need to verify vital signs before administering medications with dose-holding parameters, which was not adhered to in this case.
Resident Safety Compromised by Malfunctioning Bathroom Door
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, specifically regarding the functionality of the bathroom door. The resident, who had a history of falls and other health issues, reported that the bathroom door was too heavy to close. This issue was communicated to the nursing staff, but the resident could not recall the staff member's name. Observations confirmed that the door required significant effort to close, posing a potential risk for injury. The resident's family member also expressed concerns about the sliding bathroom door, noting that it had been problematic for several days and was dragging on the floor. Despite some repairs made by the maintenance staff, the door remained difficult to operate. The Maintenance Director acknowledged the door's issues, including its tendency to get stuck and the risk of it falling off the track. The Safety Officer confirmed these concerns, demonstrating the difficulty in sliding the door open. The facility's Administrator recognized the need for repairs after visiting the resident's room.
Failure to Follow Puree Diet Recipe
Penalty
Summary
The facility failed to prepare pureed food by methods that conserve nutritive value, flavor, and appearance, specifically for pureed baked fish and pureed carrots. During an observation, it was noted that a staff member did not follow the measurements for the pureed recipe, instead opting to eyeball the measurements to achieve the desired consistency. This practice was confirmed during an interview with the staff member, who admitted to not using the written measurements for the four servings being prepared, despite the recipe being designed for 20 servings. The Regional Executive Chef revealed that only certain staff members were allowed to make pureed foods because they were believed to know how to achieve the right consistency. However, this approach led to a deviation from the facility's policy, which mandates that recipes are followed during meal preparation. The failure to adhere to the recipe could potentially affect residents on a pureed diet, putting them at risk of receiving an inadequate diet that could impact their health.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boerne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Nursing & Rehabilitation | 1.3 mi | ★★★★★ | 2 | 0 |
| Cibolo Creek | 1.4 mi | ★★★★★ | 12 | 1 |
| Care Choice Of Boerne | 1.5 mi | ★★★★★ | 17 | 0 |
| Town And Country Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Estates At Shavano Park | 16.6 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.