Stone Oak Care Center: Pharmacy Failures Cited - TX
The citation at Stone Oak Care Center came during a complaint investigation conducted on November 20, 2025. Inspectors found the facility deficient under the federal standard requiring nursing homes to provide pharmaceutical services that meet each resident's needs, including employing or obtaining the services of a licensed pharmacist. It was one of four deficiencies cited during the inspection.
The violation was classified at Scope and Severity Level D, meaning inspectors identified it as an isolated problem. No actual harm to residents was documented. But inspectors determined there was potential for more than minimal harm.
That distinction matters. Pharmacy failures in nursing homes, even those that haven't yet hurt anyone on paper, sit at the center of some of the most serious injury patterns in long-term care. Residents in skilled nursing facilities typically carry complex medication regimens, often involving drugs with narrow safety margins where a missed dose, a wrong dose, or a dispensing delay can produce consequences that are difficult to reverse.
Stone Oak Care Center has not filed a plan of correction.
That is the part of this record that stands apart. When inspectors cite a deficiency, facilities are required to respond with a written plan explaining what went wrong, what they will do to fix it, and when the fix will be complete. The plan of correction is the basic mechanism by which regulators track whether a problem identified during an inspection actually gets addressed.
At Stone Oak Care Center, that mechanism has produced nothing.
The inspection report does not describe which residents were affected, what specific pharmaceutical services were missing, or how long the deficiency had existed before the complaint that triggered the investigation. The underlying complaint itself, the identity of whoever raised the alarm, is not disclosed in the public record. What the record does show is that someone contacted federal authorities, inspectors came, and they confirmed a problem with the facility's pharmaceutical services.
Four deficiencies in a single complaint inspection is not a minor outcome. Complaint investigations are typically narrower in scope than standard annual surveys, focused on the specific concern that prompted the visit. Finding four separate citation-worthy problems within that focused review suggests inspectors encountered issues that extended beyond whatever the original complaint described.
The pharmaceutical services standard that Stone Oak Care Center was found to have violated covers a broad range of obligations. A licensed pharmacist must be available to the facility. Drug regimens must be reviewed. Medications must be stored, labeled, and dispensed in ways that protect residents from harm. The inspection record does not specify which of these obligations the facility failed to meet.
What it specifies is the outcome: deficient, no plan of correction.
For families with relatives at Stone Oak Care Center, the absence of a correction plan means there is no public document describing what the facility intends to do differently. There is no timeline. There is no commitment on record. The deficiency exists in the inspection database, and next to the field where a plan of correction would appear, there is nothing.
Nursing home residents depend on the facilities housing them to manage medications that their own physicians prescribed. When that system breaks down, the consequences can include missed treatments for chronic conditions, undetected drug interactions, and errors that compound over days before anyone notices. The Level D classification means inspectors did not find that any of those consequences had materialized at Stone Oak Care Center by the time of the November inspection.
But potential for more than minimal harm is the regulatory language for a situation that hasn't gone wrong yet.
The facility had an opportunity to respond to that finding with a correction plan. It has not done so.
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: August 26, 2026 · Our methodology
STONE OAK CARE CENTER in SAN ANTONIO, TX was cited for violations during a health inspection on November 20, 2025.
The citation at Stone Oak Care Center came during a complaint investigation conducted on November 20, 2025.
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.