Cycle 1
Health 2025-09-05 · Fire 2025-09-05
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Boerne, TX
Cibolo Creek
2-star overall rating with 2-star inspections with $13,627 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1440 River Rd, Boerne, TX
(830) 816-5095
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
86
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-12-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,178
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.99% · Performance 23.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.73
Baseline 5.36% · Performance 6.42% · Measure score 4.73 · Achievement 4.73 · Improvement 0
Total nurse turnover
0
Performance 68.75% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.69
Baseline 3.53 hours · Performance 3.27 hours · Measure score 0.69 · Achievement 0.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.86% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 162 · Observed rate 8.02% · Lower 95% interval 7.2% |
| Discharge to community | 53.57% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 50.85% · Lower 95% interval 44.61% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.17% |
95.27%
2.9 pts better
|
Numerator 107 · Denominator 109 |
| Falls with major injury | 0.92% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 109 |
| Discharge self-care score | 53.09% |
53.69%
0.6 pts worse
|
Numerator 43 · Denominator 81 |
| Discharge mobility score | 59.26% |
50.94%
8.3 pts better
|
Numerator 48 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 1.83% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 109 · Adjusted rate 1.87% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 5.1% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 4 · Denominator 110 |
| Staff flu vaccination coverage | 48.62% |
42%
6.6 pts better
|
Numerator 53 · Denominator 109 |
| Discharge function score | 65.43% |
56.45%
9 pts better
|
Numerator 53 · Denominator 81 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 98.41% |
96.28%
2.1 pts better
|
Numerator 62 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 3.17% |
25.2%
22 pts worse
|
Numerator 2 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
97.9%
0.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 3.2% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 2.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
3.3%
1.7 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.8% · Q3 4.5% · Q4 2.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
18.9%
4.2 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 13.3% · Q3 17.8% · Q4 14.0% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
10.8%
1.1 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.3% · Q3 10.5% · Q4 11.1% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.7% |
15.4%
4.7 pts better
|
16.3%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q4 12.6% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
16.1%
6.5 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.8% · Q3 9.3% · Q4 16.7% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 1.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
15.0%
2.4 pts worse
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 21.0% · Q3 22.7% · Q4 13.2% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.2%
1.2 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 1.6% · Q3 6.8% · Q4 6.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
89.7%
8.9 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 98.6% · Q3 99.3% · Q4 97.2% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
12.0%
3.3 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
88.0%
0.1 pts worse
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
25.9%
4.4 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 28.1% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-02 · Fire 2024-08-02
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-26 · Fire 2023-05-26
10 health deficiencies
Top issue: Administration (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-09-05
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-09-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-09-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-09-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-15
E · Potential for more than minimal harm
2023-05-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-08
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-06
E · Potential for more than minimal harm
2025-09-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-05
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-25
J · Immediate jeopardy
2024-11-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-19
J · Immediate jeopardy
2024-11-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-19
J · Immediate jeopardy
2024-11-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-24
E · Potential for more than minimal harm
2024-11-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-24
D · Potential for more than minimal harm
2024-11-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-24
D · Potential for more than minimal harm
2024-11-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-24
E · Potential for more than minimal harm
2024-08-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-03
E · Potential for more than minimal harm
2024-08-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-03
E · Potential for more than minimal harm
2024-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-03
D · Potential for more than minimal harm
2024-08-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-03
D · Potential for more than minimal harm
2024-08-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-03
D · Potential for more than minimal harm
2023-12-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-12-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-12-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-07
F · Potential for more than minimal harm
2023-05-26
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-05-27
E · Potential for more than minimal harm
2023-05-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-27
D · Potential for more than minimal harm
2023-05-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-27
D · Potential for more than minimal harm
2023-05-26
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-05-27
D · Potential for more than minimal harm
2023-05-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-27
D · Potential for more than minimal harm
2023-05-26
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-05-27
D · Potential for more than minimal harm
2023-04-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-12
Penalties and ownership
What sits behind the stars
$0
2025-09-05
Payment Denial
Payment Denial · denial start 2025-10-04 · 11 days
11 day denial
$13,627
2024-11-23
Fine
Fine · fine $13,627
Fine
Ownership
Medina County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bell, Billie
Corporate Officer · Individual
Cascade-Kendall Health Services, Ltd
Operational/Managerial Control · Organization
Haney, Ronald
Operational/Managerial Control · Individual
Nearby options
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#2
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4-star overall rating with 3-star inspections with $33,937 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Town and Country Nursing and Rehabilitation Center
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2-star overall rating with 2-star inspections with $150,922 in total fines with 18 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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