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Complaint Investigation

Town And Country Nursing And Rehabilitation Center

Inspection Date: July 26, 2024
Total Violations 1
Facility ID 455796
Location Boerne, TX
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Inspection Findings

F-Tag F755

Harm Level: Immediate continue for any new hires and as part of the orientation process.
Residents Affected: Few Monitoring:

F-F755 (form) dated July 26-27, 2024, revealed only 2 residents on fentanyl patches; Resident #2 and Resident #3. The audits were contained in the facility's POR binder.

Record review of facility's Admissions/Discharge list dated 7/26/24 revealed non new admissions.

Record review of the in-service from 7/25/24 to 7/26/24 revealed 100% completion of 49 nursing staff trained

on fentanyl protocol, placement, proper disposal, location, dating, and signatures (see attached sheet). Form also present for non-license nursing staff on communications and patches found.

Record review of facility's morning report dated 7/15/24-7/26/24 revealed the report was reviewed and signed by the DON and the Administrator.

Record review of ad-hoc QAPI meeting held on 7/25/24 with the Medical Director present by telephone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 455796 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455796 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Town and Country Nursing and Rehabilitation Center 625 N Main St Boerne, TX 78006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 7/26/24 at 4:50 PM the Administrator was informed the POR was validated and Immediacy was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than Level of Harm - Immediate minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the jeopardy to resident health or implementation and effectiveness of its Plan of Removal. safety

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 455796

📋 Inspection Summary

Town and Country Nursing and Rehabilitation Center in Boerne, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Boerne, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Town and Country Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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