Carechoice of Boerne

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the confidentiality of personal and medical records for two (2) of three (3) staff (LPN A and LPN B) observed for confidentiality of records. 1. The facility failed to ensure LPN A locked the computer on the 100-Hall medication cart, which exposed 100-Hall resident names and room numbers, so the residents' information could be seen and/or accessed by someone walking by on 05/27/2026 at 09:39 a.m. 2. The facility failed to ensure LPN B locked the computer on the 200-Hall medication cart, which exposed Resident #3's medication list, so the resident's information could be seen and/or accessed by someone walking by on 05/27/2026 at 10:18 a.m. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate below 5 percent (%) or greater. The facility had a medication error rate of 100% based on 25 out of 25 opportunities which involved four (4) of four (4) residents (Resident #1, Resident #2, Resident #3, and Resident #4) and three (3) of three (3) staff (LPN A, LPN B, and LPN C) observed for medication administration errors. 1. LPN A administered Namenda (a drug used to treat moderate-to-severe dementia, the impaired ability to remember, think, or make decisions) and Pataday (an eyedrop used to treat eye itching caused by allergies) to Resident #1 on 05/27/2026 at 09:44 a.m., 44 minutes after the scheduled administration window, 07:00 a.m. to 09:00 a.m. 2. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys, for 1 of 3 medication carts (200-Hall medication cart) reviewed for security. LPN B left the 200-Hall medication cart unsupervised, unattended, and unlocked during a medication administration for approximately two (2) minutes on 05/27/2026 at 10:26 a.m. This failure could place residents at risk for misappropriation of property and or not receiving the therapeutic effects of their medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedure. [...]

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen reviewed. The facility failed to employ a qualified dietician or other clinically qualified nutrition professional on a full-time basis or designate a qualified director of nutritional services. A qualified director of nutritional services was last employed February 2025. The facility failed to employ a qualified dietician who designates a person to serve as a full-time director of food and nutrition services for the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for 1 of 2 residents (Resident #2) reviewed for abuse and neglect. The facility failed to investigate when Resident #2 had a self-inflicted injury on 9/16/2025. This deficient practice placed all residents at risk of harm from neglect due to not having a thorough investigation conducted.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change MDS assessment within 14 days after the facility determined, or should have determined, there had been a significant change in a resident's physical or mental condition for 1 of 8 residents (Resident #2) reviewed for assessments. The facility failed to complete a Significant Change MDS for Resident #2 after a self-injury incident on 9/16/2025. This failure could place residents who had a significant change in condition at risk of not receiving needed services.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 2 residents (Resident #2) reviewed for care plans. The facility failed to update or add interventions to Resident #2's care plan regarding a self-inflicted incident that occurred on 9/16/2025. These failures could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored the facility must store under proper temperature controls for 1 of 1 medication cart (100 hall cart) reviewed for medication storage. The facility failed to ensure Humalog insulin for Resident #8 was discarded after 28 days of opening. This failure could lead to reduced therapeutic effect of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #4) residents reviewed for infection control. The facility failed to ensure staff utilized proper PPE while providing incontinence care to Resident #4 on 2/11/2026 at 9:36 AM. This failure could lead to the spread of infection and illness.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of seven residents (Resident #1) reviewed for resident rights. The facility failed to ensure. Resident #1 was provided with effective communication strategies to help her convey her daily needs and the nursing staff were not provided with communication strategies to assist Resident #1 to improve effective communication abilities for her day-to-day activities. These failures could place residents at risk of diminished dignity and affect their quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that each resident's MDS assessment accurately reflects the resident's status for one of seven residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure the 09/04/2025 MDS assessment accurately reflected Resident #1's cognitive status and the resident's use of hearing aids, which had been lost as of 08/24/2025 This failure could place residents at risk for inaccurate care planning and care delivery.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one of seven residents (Resident #1) reviewed for care plans. The facility failed to update or add interventions to Resident #1's care plan regarding the loss of her hearing aids that impacted her communication abilities. This failure could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 3 residents (Residents #20 and #25) reviewed for accidents/hazards, in that: 1. Resident #20 was provided a fall intervention on 05/23/2024 to include an anti-rollback device affixed to his wheelchair. Intermittent observations from 11/19/2024 thru 11/22/2024 revealed Resident #20 was observed ambulating in his wheelchair without a functioning ant-rollback device. 2. Resident #25 was provided a fall intervention on 09/22/2023 to include an anti-rollback device affixed to her wheelchair. Intermittent observations from 11/19/2024 thru 11/22/2024 revealed Resident #25 was observed ambulating in her wheelchair without a functioning ant-rollback device. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 2 of 10 residents (Residents #43 and #47) reviewed for significant medication errors. 1. On 11/21/2024 at 09:45 AM, LVN E administered to Resident #43 memantine (used to treat moderate to severe confusion (dementia) related to Alzheimer's disease) 10mg to Resident #43 late by 45 minutes. 2. On 11/21/2024 at 09:54 AM, LVN E administered to Resident #47: A. Valsartan (used to treat high blood pressure and heart failure. It is also used to improve the chance of living longer after a heart attack.) 160mg late by 54 minutes. B. Levetiracetam (a drug used to suppress seizures) 500mg late by 54 minutes. C. Divalproex 250mg (a drug used to prevent seizures, mood disorders, and migraine headaches) late by 54 minutes . [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized, for 3 of 8 residents reviewed (Residents #7, #38, and #16) for complete and accurate medical records 1. The facility failed to ensure Resident #7's signed out of hospital do not resuscitation order form was properly uploaded in her medical record and did not contain another residents' (Resident #38's) signed OOH DNR order form; 2. The facility failed to ensure Resident #38's signed OOH DNR order form was properly uploaded in her medical record; 3. The facility failed to ensure Resident #16's signed OOH DNR order form was properly uploaded in her medical record.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 8.0% (percent), based on 2 errors out of 25 opportunities which involved 1 of 6 residents (Resident #29) reviewed for medication administration and medication errors. 1. LVN E administered Resident #29's medications: metformin (medication for managing high blood sugar in type 2 diabetes) 1000mg and metoprolol tartrate (an immediate-release tablet that must be taken several times per day) 25mg, scheduled at 08:00 AM, at 09:30 AM thirty minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infection for 1 of 10 residents (Resident #31) reviewed for infection control. The facility failed to ensure hand hygiene was initiated between glove changes during blood glucose monitoring and administration of insulin to Resident #31 on 11/21/2024. This deficient practice could affect all residents by contributing to the bacteria load and/or cross contamination during provision of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to be free from abuse for 1 of 11 residents (Resident #2) reviewed for abuse, in that: The facility failed to protect Resident #2 from Resident #3 during a resident-to-resident altercation on 09/21/2024. The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on 09/21/2024 and ended on 09/24/2024. The facility had corrected the non-compliance before the state's investigation began on 10/29/2024 at 9:30 a.m. This deficient practice could place residents at risk of physical injury and/or psychosocial harm.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure 1 (Resident #1) of 7 residents reviewed for mechanical device used by staff received adequate supervision and assistance with devices to prevent accidents. On [DATE] Agency nurse aide A transferred Resident#1 with a mechanical lift by herself. The mechanical lift tipped over causing Resident #1 to obtain a head laceration and a left femur fracture requiring surgery. The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the state's investigation began on [DATE] at 9:30 AM. Failure of facility to provide adequate supervision and assistance with devices could lead to injury or death to residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for 1 (Resident #1) of 4 residents reviewed in that: Resident #1's care plan was incomplete and did not accurately describe his care need to have his coffee served in a mug with a tight lid to prevent coffee spills. This failure could place residents at risk of not receiving care as ordered and needed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protect and promote the rights of the Resident, for 1 (Resident #34) of 49 residents reviewed for dignity in that; The facility assisted Resident #34 with meals while identifying Resident #34 as a Feeder. This failure placed residents at risk for undignified treatment and threatened residents' self-esteem.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident has a right to personal privacy for 1 of 13 residents (Resident #25) reviewed for dignity, in that: 1. Housekeeper D entered the Shower room after CNA B and CNA C stated patient care X 3 while showering resident # 25. This deficient practice could place residents at risk of loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state laws through established procedure for 1 of 8 (Resident #45) residents reviewed for abuse and neglect, in that: The facility failed to report an allegation of abuse to the State Survey Agency within 24 hours of being made by Resident #45. This deficient practice could place residents at risk of allegations not fully being investigated, and abuse, neglect, misappropriation, and exploitation.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 1 medication storage room, reviewed for security, in that; The medication storage room was unattended and unlocked. This failure could place residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 food storage locations, an ice maker, and refrigerator reviewed for food safety, in that; 1. The facility's ice maker machine presented with pink and black residues inside the ice storage compartment. 2. The residents' snack refrigerator presented with fresh foods without labeled dates to indicate a throw away date. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff and obtain the required information for 1 of 12 (Resident # 48) reviewed for hospice services, in that: 1. The facility failed to obtain Resident #48's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, and documentation by specific interdisciplinary hospice staff providing services This failure could place the resident who received hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal privacy of personal care for 1 of 3 residents (R#3), reviewed for privacy. R#3's catheter bag containing urine did not have a privacy bag and was visible to staff, residents (R#5), and visitors. R#5 was the roommate to R#1. The deficiency could create psychosocial harm to residents with an indwelling catheter and deny the residents privacy and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Dishwasher A was observed in the dish room with no hairnet. Dishwasher B observed to not have a hairnet while preparing lunch. This could place residents at risk for food contamination.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 4 (Resident #12) residents reviewed in that: Resident #12's call light was not within reach while she was in bed. This could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs.