Stone Oak Care Center: Infection Control Failures - TX
The November 20 complaint investigation found that Stone Oak Care Center had failed to provide and implement an infection prevention and control program. Inspectors classified the violation as isolated, meaning they documented it in a specific instance rather than as a pattern running through the facility. They found no actual harm to residents. They did find potential for more than minimal harm.
That distinction matters less than it might appear. Infection control failures in nursing homes are not abstract regulatory checkboxes. They are the mechanism by which illness moves from one resident to another, from a staff member's hands to a wound, from a contaminated surface to a resident who cannot fight what lands there.
Stone Oak Care Center serves a population that is, almost by definition, medically vulnerable. Residents in long-term care facilities are older, often immunocompromised, frequently dealing with open wounds, catheters, or respiratory conditions that create direct pathways for infection to cause serious harm. An infection control program exists to interrupt those pathways before they become hospitalizations, sepsis, or worse.
The inspectors who visited in November found the program wasn't being implemented the way it needed to be. The inspection report does not detail exactly what broke down, which specific practice was missing or ignored, which moment an inspector watched and noted as the violation. What the record shows is the citation, the category, and the correction status.
The correction status reads: no plan of correction.
That is not a technicality. Facilities cited for deficiencies are expected to respond with a written plan describing what went wrong, what they will do to fix it, and when the fix will be complete. It is one of the few mechanisms that gives inspectors and the public any window into whether a facility takes its own failures seriously. Stone Oak Care Center has not provided one.
The complaint investigation that triggered the November visit produced four total deficiencies. The infection control citation was one of four problems inspectors found worth documenting. The inspection report available does not describe the other three, but the pattern of a complaint-driven visit yielding multiple citations is not unusual in facilities where compliance is uneven.
What is unusual, or at least notable, is the absence of any corrective response. Facilities sometimes dispute citations. They file appeals, argue scope, contest the inspector's characterization of what they observed. That process, whatever its outcome, at least produces a record of engagement. A missing plan of correction produces no record at all.
Infection control in nursing homes drew sustained national attention during the COVID-19 pandemic, when the consequences of inadequate programs became visible in ways they typically are not. Residents died in large numbers in facilities that lacked the procedures, the supplies, or the trained staff to stop transmission once it began. The lesson was not new to anyone who had watched nursing home inspections closely. Infection control violations have appeared consistently in federal inspection data for years, across facility types and ownership structures, in states with aggressive enforcement and states without it.
The severity level assigned to the Stone Oak citation, a "D" on the federal scale, sits at the lower end of the range. It means isolated, not widespread. It means potential harm, not documented harm. Regulators use that scale to prioritize their responses, and a "D" level deficiency does not carry the same immediate urgency as a finding of actual harm or immediate jeopardy.
But a "D" citation with no plan of correction is a different thing than a "D" citation with a documented response. One represents a facility that identified a gap and committed to closing it. The other is a citation sitting open.
The residents at Stone Oak Care Center did not file the complaint that brought inspectors through the door. Someone did, and inspectors found enough to cite the facility four times. The people living there now are the same population that was living there in November, in a building where inspectors found an infection prevention program not being implemented as it should be, and where no one has yet put in writing what will change.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stone Oak Care Center from 2025-11-20 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: September 9, 2026 · Our methodology
STONE OAK CARE CENTER in SAN ANTONIO, TX was cited for violations during a health inspection on November 20, 2025.
The November 20 complaint investigation found that Stone Oak Care Center had failed to provide and implement an infection prevention and control program.
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.