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Nursing HomeMedicaid Investigative

Cibolo Creek

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1440 River Rd, Boerne, TX 78006120 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.0/5

based on 38 Google reviews

5
4
3
2
1

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Low staffing rating (1/5 stars)
  • High staff turnover (64%)
  • High RN turnover (54%)

Below average in Texas · $13,627 in fines

Source: Medicare data

What this means for your family

This facility is an excellent choice for rehabilitation and social engagement due to their superior therapy programs and vibrant activity calendar. However, families must be vigilant regarding hygiene and communication; we recommend frequent unannounced visits to ensure nursing responsiveness and cleanliness standards are being met.

Google Reviews

Google Reviews

38 reviews on Google
Families considering Cibolo Creek will find a facility highly praised for its exceptional rehabilitation services and engaging social activities like live music and dominoes. However, there are serious, recurring reports of neglect regarding hygiene and slow response times from nursing staff, as well as inconsistent communication from administration during transitions of care.

Quality Themes

Tap a score for details
Food5.0Staff7.0Clean6.0Activities10.0MedsN/AMemory8.0Comms3.0ValueN/A

Strengths

  • Exceptional rehabilitation and physical therapy
  • Engaging social activities and live music
  • Compassionate and attentive nursing staff
  • Clean and well-maintained facility

Concerns

  • Inconsistent hygiene and odor management (mentioned by 2 reviewers)
  • Slow nursing response times and neglect (mentioned by 2 reviewers)
  • Poor communication from administration and doctors (mentioned by 2 reviewers)
  • Staffing shortages/short-staffed (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'16(2)'18(3)'21(3)'23(4)'25(13)'26(3)

Distribution · 41 analyzed

5
26
4
6
3
0
2
1
1
8

How They Respond to Reviews

50%response rate
Good

The owner provides personalized responses to positive reviews, often using the reviewer's name and acknowledging specific staff members. For negative reviews, they use a professional, apologetic tone and attempt to move the conversation to a private phone line.

Questions for Your Tour

  • 1We've heard great things about your physical therapy and rehab programs; could you tell us more about how those are integrated into a resident's daily routine?
  • 2How does the nursing team ensure that calls for assistance are answered promptly, especially during busy shift changes?
  • 3What specific steps does the facility take to maintain a fresh and clean environment, particularly regarding daily room maintenance and odor management?
  • 4Can you describe the variety of social activities and live music events available to keep residents engaged and connected?
  • 5How does the administration ensure that families are kept in the loop regarding updates from doctors or changes in a resident's care plan?
  • 6In the event of a medical emergency after hours, what is the protocol for notifying the family and coordinating with physicians?

Personalized based on this facility's data


Key Review Excerpts

The activities are the best too!! They have added dominos for him to the daily options because he loves it. They have also added live music twice a week!!

Long-term resident's family · 2025★★★★★

My mother was in Cibolo Creek as a long term resident. She was there for over 10 years and I cannot say enough about the care my mom received. The staff was very sweet and concerned for my mom.

Long-term resident's family · 2025★★★★★

The place is a disgrace. We visited nearly everyday and everyday she declined more. The place smelled strongly of urine. I told them that the smell of urine in the halls was nauseating.

Rehab patient's family · 2025☆☆☆☆
Source: 38 Google reviews

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

11

measures

Worse Than Avg

1

measures

Mixed Results

5

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.4%
Better than Avg
Here
1.4%
US
12.1%
TX
2.5%
Kendall
18.5%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility15.5%
Better than Avg
Here
15.5%
US
19.5%
TX
18.4%
Kendall
30.0%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility9.7%
Better than Avg
Here
9.7%
US
14.4%
TX
16.1%
Kendall
22.8%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.7%
Better than Avg
Here
8.7%
US
15.3%
TX
14.9%
Kendall
21.2%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.6%
Better than Avg
Here
99.6%
US
93.4%
TX
96.9%
Kendall
96.2%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility9.7%
Mixed vs Avgs
Here
9.7%
US
15.4%
TX
9.4%
Kendall
9.6%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility97.6%
Better than Avg
Here
97.6%
US
81.8%
TX
89.2%
Kendall
90.9%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility87.9%
Mixed vs Avgs
Here
87.9%
US
79.7%
TX
88.0%
Kendall
83.1%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.2%
Better than Avg
Here
1.2%
US
1.6%
TX
1.5%
Kendall
2.4%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

6deficiencies
2penalties
Near state avg (9.1)
10 complaint-triggered
$13,627 in fines

This facility has a concerning pattern of repeated problems across multiple areas, with families filing 10 complaints that triggered federal investigations. The most recurring issues involve care planning, accident prevention and safety hazards, medication management, and food safety. Problems with care planning and safety supervision have persisted across multiple surveys, suggesting ongoing challenges in ensuring resident wellbeing and preventing accidents.

Sep 5, 2025Routine
12
0689Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0916Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have a battery powered remote alarm panel in a location accessible by operating personnel.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0919Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0923Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0908Potential for harm · PatternCorrected

Environmental Deficiencies

Keep all essential equipment working safely.

0607Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0293Potential for harm · IsolatedCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Nov 23, 2024Complaint
6
0580Immediate jeopardy · IsolatedResolved (past non-compliance)

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0684Immediate jeopardy · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Aug 2, 2024Routine
5
0558Potential for harm · PatternCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Dec 29, 2023Complaint
3
0607Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0602Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

0755Potential for harm · IsolatedResolved (past non-compliance)

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

May 26, 2023Routine
7
0847Potential for harm · WidespreadCorrected

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

0760Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0808Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

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.

0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0848Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Apr 11, 2023Complaint
1
0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

Federal Penalties

Payment Denial

Sep 5, 2025

11-day denial

Fine

Nov 23, 2024

$13,627

Ownership & Operations

Who Operates This Facility

Owner / Operator

Medina County Hospital District

Organization Type

for profit

Management Company

CASCADEKENDALL HEALTH SERVICES, LTD

Administrator

TAYLOR COLLIER

Ownership & Management

Owners

Medina County Hospital District

Owner · Organization

100%

Dorrow, Marjorie

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Haney, Max

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Bell, BillieOfficer / DirectorCascade-Kendall Health Services, LtdManagerHaney, RonaldManagerBoerne Hc LLCAdp of the SnfCollier, TaylorAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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