Town and Country Nursing Center: Drug Monitoring Lapse, TX
BOERNE, TX - Federal inspectors removed an immediate jeopardy designation from a local nursing facility after administrators implemented emergency corrective measures to address serious medication management concerns involving fentanyl patches, potent opioid pain relievers that require strict handling protocols.
Emergency Response to Medication Safety Concerns
Town and Country Nursing and Rehabilitation Center faced a federal complaint investigation on July 26, 2024, that initially identified conditions posing immediate jeopardy to resident safety. The inspection focused on the facility's systems for tracking and managing fentanyl patches, a controlled substance requiring enhanced monitoring due to its high potency and potential for diversion or misuse.
Federal surveyors documented deficiencies in the facility's Plan of Removal (POR) process, which nursing homes must implement when immediate jeopardy conditions are identified. By 4:50 PM on the inspection date, administrators had taken sufficient corrective action to have the immediate jeopardy designation removed, though the facility remained cited for deficiencies that could potentially cause more than minimal harm to residents.
The inspection revealed that only two residents in the facility were receiving fentanyl patches at the time of the survey. While the small number of affected residents limited the scope of potential harm, the nature of the violations warranted immediate intervention due to the serious risks associated with improper controlled substance management.
Understanding Fentanyl Patch Protocols
Fentanyl is a synthetic opioid approximately 50 to 100 times more potent than morphine. When administered through transdermal patches, the medication delivers continuous pain relief over 72-hour periods for residents experiencing severe, chronic pain conditions. The potency of fentanyl necessitates rigorous monitoring protocols in long-term care settings.
Proper fentanyl patch management requires multiple layers of oversight. Staff must document the exact placement location on each resident's body to ensure patches are rotated to different sites, preventing skin irritation and ensuring consistent absorption. Each patch must be dated and initialed to verify when it was applied and who performed the application. When patches are changed, used patches must be folded sticky-side together and immediately disposed of in designated pharmaceutical waste containers, as residual medication remains in used patches.
Federal regulations require nursing facilities to implement comprehensive controlled substance management systems. These systems must include regular audits of medication administration records, physical verification that patches are present on residents when documented, staff training on proper handling procedures, and monitoring for signs of diversion or misuse.
Corrective Measures Implemented
Following identification of the deficiencies, facility leadership took immediate steps to address the medication management concerns. Documentation reviewed by surveyors showed that 49 nursing staff members completed mandatory training on July 25-26, 2024, covering fentanyl protocols, proper patch placement techniques, disposal procedures, documentation requirements for location tracking, and signature verification procedures.
The training achieved 100% completion among nursing staff, indicating the facility prioritized rapid education to prevent future incidents. Additional training was provided to non-licensed nursing staff focusing on communication protocols and procedures for reporting any patches found outside of designated locations, such as on floors, in bedding, or in other unexpected areas.
Facility administrators also implemented enhanced audit procedures. Review of the facility's POR binder revealed documentation of audits specifically tracking the two residents receiving fentanyl patches. These audits represented a systematic approach to verifying that patches were present where documented, properly dated and initialed, and changed according to prescribed schedules.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Town and Country Nursing and Rehabilitation Center in Boerne, TX was cited for violations during a health inspection on July 26, 2024.
The inspection revealed that only two residents in the facility were receiving fentanyl patches at the time of the survey.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.