Care Choice of Boerne: Medication Cart Left Unlocked - TX
The incident happened on the morning of May 27, 2026. Inspectors were watching LPN B make her way through medication rounds on the 200-Hall when, at 10:26 a.m., she picked up a cup of prepared medications for Resident 3, stepped away from the cart, and entered the resident's room to administer them at bedside. The cart stayed behind in the hallway. Unlocked. Facing outward.
She returned two minutes later, at 10:28 a.m.
LPN B told inspectors immediately after that she knew she was supposed to lock the cart when she stepped away. She said she simply didn't realize she hadn't done it. She acknowledged that if a patient had come by, they could have opened it. She offered one partial reassurance: the narcotics inside were secured in a separately locked compartment, and the punch cards holding most of the other medications would have been hard for a resident to access on their own.
That was her read of the risk. The cart was still unlocked. Nobody was watching it.
The administrator, interviewed the following afternoon, said his understanding was clear: nursing staff should secure the cart the moment they pull away from it. The director of nursing said the same thing in a separate interview forty minutes later. Her expectation, she said, was that the cart gets locked any time a nurse is walking away, no exceptions. The concern she named was straightforward: medications left unsecured could be accessed by a resident, or by anyone else who shouldn't have them.
The facility's own written policy, last revised in April 2019, says the medication cart must be kept closed and locked whenever it is out of sight of the nurse administering medications. There is a specific allowance for leaving the cart in a doorway, but only with the open drawers facing inward into the room, not outward toward the hall. LPN B's cart was in the hallway, facing out.
Inspectors noted there were no residents or visitors in the immediate area during those two minutes. Nobody approached the cart. Nothing was taken. The harm level was recorded as minimal, affecting a small number of residents.
But the inspection wasn't called because everything was fine. It was a complaint inspection, meaning someone had already raised a concern about the facility before investigators arrived. The unlocked cart was what they found when they got there.
The scenario LPN B described, where a passing resident might open the cart, is not abstract in a nursing home setting. Residents with dementia or confusion move through hallways. Visitors come and go. Two minutes is enough time.
What the inspection captured was a nurse who knew the rule, had internalized it well enough to explain it back to inspectors on the spot, and still didn't follow it. Not out of indifference, by her own account, but because she didn't notice. That gap, between knowing what to do and actually doing it in the middle of a busy medication round, is where the risk lives.
The director of nursing and the administrator both described the policy correctly when asked. The policy document existed and was up to date. The cart was still left unlocked in the hallway for two minutes while a nurse was in another room.
Care Choice of Boerne had two other medication carts reviewed during the same inspection. Inspectors found no problems with either of them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care Choice of Boerne from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
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: August 8, 2026 · Our methodology
CARE CHOICE OF BOERNE in BOERNE, TX was cited for violations during a health inspection on May 28, 2026.
The incident happened on the morning of May 27, 2026.
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.