Care Choice of Boerne: Medication Timing Failures - TX
The nurse, identified in inspection records as LPN A, began preparing the medications for Resident 4 at 10:05 a.m. on May 27. Every one of the eleven drugs on the screen, including folic acid, Pepcid, allopurinol, iron, a multivitamin, thiamine, Lexapro, metformin, magnesium oxide, metoprolol tartrate, and zinc, had been scheduled for 9:00 a.m. LPN A administered them at 10:18 a.m., seventy-eight minutes after they were due.
The metoprolol order carried specific instructions: hold the dose if the resident's systolic blood pressure dropped below 110, diastolic below 60, or heart rate below 60. The metformin was prescribed twice daily, at 9:00 a.m. and again at 5:00 p.m. The Lexapro, prescribed for major depressive disorder, was a once-daily morning dose.
LPN A told inspectors she was familiar with the facility's medication administration policy. That policy, revised in April 2019, states medications are to be administered within one hour of their prescribed time. It also states that administration times are determined by resident need and benefit, not staff convenience, and that factors including optimal therapeutic effect and potential food or drug interactions are to be considered when setting those times.
The facility's own error policy, revised as recently as June 2025, lists wrong-time administration as an example of a medication error.
The administrator told inspectors on May 28 that staff had a two-hour window, one hour before and one hour after the scheduled time, to give a medication. He said he could not assess the impact of a late dose without knowing what the medication was for, but offered that a pain medication given late might leave a resident uncomfortable before the drug had a chance to level off.
The director of nursing gave a similar answer. She said late administration could affect a resident if the next dose ended up being issued too soon as a result of the delay, but she framed the two-hour window as standard facility procedure. She acknowledged that a compressed interval between doses could affect the resident.
Neither the administrator nor the director of nursing addressed the specific medications Resident 4 had been waiting for, or what a 78-minute delay meant for a twice-daily diabetes drug or a blood pressure medication governed by a hold order.
The inspection was conducted in response to a complaint. Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, with some residents affected.
What the records do not show is whether anyone checked Resident 4's blood pressure or heart rate before LPN A finally administered the metoprolol, more than an hour after it was due.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 21, 2026 · Our methodology
CARECHOICE OF BOERNE in BOERNE, TX was cited for violations during a health inspection on May 28, 2026.
The nurse, identified in inspection records as LPN A, began preparing the medications for Resident 4 at 10:05 a.m.
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.