Cibolo Creek

1440 River Rd · Boerne, TX · 78006 · 8308165095

120 certified beds Government - Hospital district

Why this verdict

  • Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
  • Inspection record is far worse than the national median (deficiency count and severity).

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Red flags

1 immediate-jeopardy citation in the most recent inspection cycle

Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.

Medicare/Medicaid payments were denied

CMS refused payment for new admissions for a period — one of its strongest enforcement tools.

64% of nursing staff left within a year

High turnover disrupts continuity of care; the national median is 45%.

Score breakdown

Inspection record 30% of score 36
Serious harm & abuse 20% 52
Staffing 20% 55
Federal penalties 15% 56
Trend 10% 73
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 4 of 5

Total nurse hours / resident-day3.183.48 min · 4.1 strong
RN hours / resident-day0.500.55–0.75
Weekend hours / resident-day2.91≈ weekday level
Nursing turnover / year64%median 45%
Fines (3-yr window)1 · $13,627

Inspection citations (26 in the current record)

  • Immediate jeopardy · J September 5, 2025

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

    Corrected September 6, 2025 · Quality of Life and Care

  • Potential for harm · E September 5, 2025

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

    Corrected September 25, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D September 5, 2025

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

    Corrected September 25, 2025 · Resident Assessment and Care Planning

  • Potential for harm · E September 5, 2025

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

    Corrected September 25, 2025 · Nutrition and Dietary

  • Potential for harm · E September 5, 2025

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

    Corrected September 25, 2025 · Resident Assessment and Care Planning

  • Potential for harm · E September 5, 2025

    Keep all essential equipment working safely.

    Corrected September 25, 2025 · Environmental

  • Immediate jeopardy · J November 23, 2024 · found via complaint

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

    Corrected November 19, 2024 · Resident Rights

  • Immediate jeopardy · J November 23, 2024 · found via complaint

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

    Corrected November 19, 2024 · Quality of Life and Care

  • Immediate jeopardy · J November 23, 2024 · found via complaint

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

    Corrected November 24, 2024 · Quality of Life and Care

  • Potential for harm · D November 23, 2024 · found via complaint

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

    Corrected November 24, 2024 · Resident Assessment and Care Planning

  • Potential for harm · E November 23, 2024 · found via complaint

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

    Corrected November 24, 2024 · Pharmacy Service

  • Potential for harm · D November 23, 2024 · found via complaint

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

    Corrected November 24, 2024 · Resident Assessment and Care Planning

  • Potential for harm · E August 2, 2024

    Reasonably accommodate the needs and preferences of each resident.

    Corrected August 3, 2024 · Resident Rights

  • Potential for harm · D August 2, 2024

    Keep residents' personal and medical records private and confidential.

    Corrected August 3, 2024 · Resident Rights

  • Potential for harm · D August 2, 2024

    Ensure each resident receives an accurate assessment.

    Corrected August 3, 2024 · Resident Assessment and Care Planning

  • Potential for harm · E August 2, 2024

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

    Corrected August 3, 2024 · Nutrition and Dietary

  • Potential for harm · E August 2, 2024

    Provide and implement an infection prevention and control program.

    Corrected August 3, 2024 · Infection Control

  • Potential for harm · D December 29, 2023 · found via complaint

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

    Corrected October 2, 2023 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D December 29, 2023 · found via complaint

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

    Corrected August 28, 2023 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D December 29, 2023 · found via complaint

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

    Corrected October 7, 2023 · Pharmacy Service

  • Potential for harm · D May 26, 2023

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

    Corrected May 27, 2023 · Quality of Life and Care

  • Potential for harm · E May 26, 2023

    Ensure that residents are free from significant medication errors.

    Corrected May 27, 2023 · Pharmacy Service

  • Potential for harm · D May 26, 2023

    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 May 27, 2023 · Nutrition and Dietary

  • Potential for harm · D May 26, 2023

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

    Corrected May 27, 2023 · Nutrition and Dietary

  • Potential for harm · F May 26, 2023

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

    Corrected May 27, 2023 · Administration

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
September 5, 2025Payment Denial11 days
November 23, 2024Fine$13,627

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676240 · certified since December 2, 2009. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.