Cibolo Creek
1440 River Rd, Boerne, TX 78006 · Kendall County · 120 certified beds · avg 89 residents/day · certified since Dec 2, 2009
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 5, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 6, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 23, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 19, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Nov 23, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 19, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Nov 23, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 24, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 5, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 23, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Nov 23, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Nov 23, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 2, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Aug 2, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 2, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 2, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Aug 2, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 29, 2023 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Dec 29, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Dec 29, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| May 26, 2023 | F · Potential for harm, facility-wide | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| May 26, 2023 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not provide a neutral and fair arbitration process. Arbitration is a way of settling disputes outside of court, and if it's used, the facility must agree with the resident on a neutral arbitrator and a convenient location. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | F |
| 2024 | 11 | 3 | J ▲ |
| 2025 | 6 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $13,627, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Sep 5, 2025 | Payment Denial | 11 days from Oct 4, 2025 |
| Nov 23, 2024 | Fine | $13,627 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.47 | 3.46 | 3.95 | top 37% in Texas; bottom 35% in the U.S. |
| Registered Nurse hours | 0.53 | 0.44 | 0.69 | top 22% in Texas; bottom 43% in the U.S. |
| Weekend total nurse staffing | 3.00 | 3.04 | 3.50 | top 41% in Texas; bottom 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.20 | 0.34 | 0.48 | bottom 24% in Texas; bottom 13% in the U.S. |
| Total nursing staff turnover (%) | 60.8 | 55.3 | 45.8 | bottom 32% in Texas; bottom 15% in the U.S. |
| RN turnover (%) | 58.3 | 54.6 | 42.9 | bottom 43% in Texas; bottom 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.00, RN 0.46, weekend 2.59. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 2/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Medina County Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/01/2021 |
| Bell, Billie | Individual | Corporate Officer | NOT APPLICABLE | 06/03/2023 |
| Boerne HC LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2021 |
| Cascade-Kendall Health Services, LTD | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Collier, Taylor | Individual | ADP of the SNF | NOT APPLICABLE | 08/22/2023 |
| Dorrow, Marjorie | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/17/2025 |
| Haney, Max | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/17/2025 |
| Haney, Ronald | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2021 |
| Haney, Ronald | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2021 |
| Sorrells, John | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Boerne | 0.1 mi | Boerne, TX | ★☆☆☆☆ | 1/5 | |
| Carechoice of Boerne | 1.1 mi | Boerne, TX | ★★☆☆☆ | 3/5 | |
| Town and Country Nursing and Rehabilitation Center | 1.3 mi | Boerne, TX | ★☆☆☆☆ | 2/5 | |
| Kendall House Wellness & Rehabilitation | 1.4 mi | Boerne, TX | ★★★☆☆ | 4/5 | |
| Estates at Shavano Park | 16.8 mi | Shavano Park, TX | ★★★☆☆ | 3/5 | |
| Coronado at Stone Oak | 17.0 mi | San Antonio, TX | ★★★★★ | 4/5 | |
| Avir at Comfort | 17.1 mi | Comfort, TX | ★★★★★ | 4/5 | |
| Stone Oak Care Center | 17.6 mi | San Antonio, TX | ★★☆☆☆ | 3/5 | |
| The Heights of Bulverde | 17.7 mi | Spring Branch, TX | ★★☆☆☆ | 2/5 | |
| Sonterra Health Center | 17.9 mi | San Antonio, TX | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676240.