Cycle 1
Health 2024-10-11 · Fire 2024-10-11
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Boerne, TX
Kendall House Wellness & Rehabilitation
3-star overall rating with 3-star inspections with $88,390 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1050 Grand Blvd., Boerne, TX
(830) 816-4100
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-07-01
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
0.92
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.56
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.75
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.48
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.39
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,502
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.18% · Performance 22.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.29
Baseline 6.45% · Performance 6.85% · Measure score 3.29 · Achievement 3.29 · Improvement 0
Total nurse turnover
2.31
Baseline 82.98% · Performance 66.67% · Measure score 2.31 · Achievement 0 · Improvement 2.31
Adjusted total nurse staffing
3.79
Baseline 4.76 hours · Performance 4.16 hours · Measure score 3.79 · Achievement 3.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 245 · Observed rate 9.8% · Lower 95% interval 7.31% |
| Discharge to community | 65.89% |
50.57%
15.3 pts better
|
Better than the National Rate · Eligible stays 225 · Observed rate 62.22% · Lower 95% interval 59.21% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 143 · Denominator 143 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 143 |
| Discharge self-care score | 87.5% |
53.69%
33.8 pts better
|
Numerator 91 · Denominator 104 |
| Discharge mobility score | 65.38% |
50.94%
14.4 pts better
|
Numerator 68 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 2.1% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 143 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 5.96% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 10% |
8.2%
1.8 pts better
|
Numerator 4 · Denominator 40 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 43 |
| Discharge function score | 82.69% |
56.45%
26.2 pts better
|
Numerator 86 · Denominator 104 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 98.89% |
96.28%
2.6 pts better
|
Numerator 89 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 18.9% |
3.3%
15.6 pts worse
|
3.3%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.2% |
2.7%
18.5 pts worse
|
11.4%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.3%
0.9 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.7% |
18.9%
17.8 pts worse
|
19.6%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.7% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 13.1% |
0.5%
12.6 pts worse
|
1.0%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
15.0%
13 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 19.1% |
4.2%
14.9 pts worse
|
5.1%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
89.7%
9.6 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 99.4% · Q3 100.0% · Q4 99.3% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.2% |
12.0%
7.2 pts worse
|
12.0%
7.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 18.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.1% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
88.0%
2.4 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
25.9%
0.7 pts better
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 25.4% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-07-15 · Fire 2022-07-15
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-19
D · Potential for more than minimal harm
2023-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-02
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 2025-01-29
J · Immediate jeopardy
2024-11-24
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 2024-12-30
E · Potential for more than minimal harm
2024-10-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-10-11
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 2024-11-19
D · Potential for more than minimal harm
2024-10-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-19
E · Potential for more than minimal harm
2023-09-08
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 2023-09-11
E · Potential for more than minimal harm
2023-09-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-09-08
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-09-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-09-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-09-08
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 2023-09-11
D · Potential for more than minimal harm
2023-09-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-09-08
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-18
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 2023-10-05
E · Potential for more than minimal harm
2022-07-15
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 2022-08-04
E · Potential for more than minimal harm
2022-07-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-07-15
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-07-15
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-07-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-07-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-07-18
Penalties and ownership
What sits behind the stars
$88,390
2024-11-24
Fine
Fine · fine $88,390
Fine
$0
2024-11-24
Payment Denial
Payment Denial · denial start 2024-12-24 · 6 days
6 day denial
Ownership
Morningside Ministries
5% Or Greater Direct Ownership Interest · Organization
Asis, Rissa
Operational/Managerial Control · Individual
Bryan, Scott
Corporate Director · Individual
Crump, Patrick
Corporate Officer · Individual
Drought, Jessica
Corporate Director · Individual
Forgione, Dana
Corporate Director · Individual
Garza, Edward
Corporate Director · Individual
Hackett, Greg
Corporate Director · Individual
Kercheville, Scott
Corporate Director · Individual
Mccullough, Robert
Corporate Director · Individual
Mcrae, Thomas
Corporate Director · Individual
Mendoza, Dora
Corporate Director · Individual
Mobley, Jessica
Corporate Director · Individual
Monfrey, Margaret
Operational/Managerial Control · Individual
Moore, Joe
Corporate Director · Individual
Moreno, Chelsea
Operational/Managerial Control · Individual
Moreno, Chelsea
Corporate Officer · Individual
Munoz, Dionicio
Operational/Managerial Control · Individual
Nguyen, Chrisine
Operational/Managerial Control · Individual
Ortiz, Robert
Corporate Director · Individual
Osanyinlusi, Lisa
Operational/Managerial Control · Individual
Phipps, Amy
Corporate Director · Individual
Powell, Brooks
Operational/Managerial Control · Individual
Prater, Myranda
Operational/Managerial Control · Individual
Read, David
Corporate Director · Individual
Robertson, Cassandra
Operational/Managerial Control · Individual
Scofield, George
Corporate Director · Individual
Tye, Richard
Corporate Director · Individual
Youngquist, Holly
Corporate Director · Individual
Nearby options
Other facilities in reach
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Riverview Nursing & Rehabilitation
Boerne, TX
2-star overall rating with 1-star inspections with $156,748 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Cibolo Creek
Boerne, TX
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
#3
Care Choice Of Boerne
Boerne, TX
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
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