Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Kendall House Wellness & Rehabilitation during CMS and state inspections, most recent first.
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.
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 | — | 0 | 0 |
| Cibolo Creek | 1.4 mi | — | 0 | 0 |
| Care Choice Of Boerne | 1.5 mi | — | 14 | 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 August 2026) and official state health department websites.