Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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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) |
|---|---|---|---|---|
| Town And Country Nursing And Rehabilitation Center | 0.2 mi | — | 5 | 0 |
| Riverview Nursing & Rehabilitation | 1.1 mi | — | 0 | 0 |
| Cibolo Creek | 1.1 mi | — | 0 | 0 |
| Kendall House Wellness & Rehabilitation | 1.5 mi | — | 7 | 0 |
| Avir At Comfort | 16 mi | — | 0 | 0 |
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