Stone Oak Care Center
Inspection Findings
F-Tag F0641
F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident #1's Quarterly MDS Assessment, dated 10/27/2025 and signed as completed on 11/03/2025 by
the RNAC, reflected assessment observation end date of 10/27/2025. Resident #1 had a BIMS score of 15 indicating he was cognitively intact. Under Any Falls Since Admission/Entry or Reentry or Prior Assessment, Resident #1 was coded as having not had a fall since admission/entry or reentry or the prior assessment. The section for fall history was noted to have been signed as completed by the RNAC. Record
review of Resident #1's comprehensive care plan, dated as last care plan review completed 09/09/2025, reflected I am at risk for falls r/t: .10/7/25, date initiated and created 08/16/2025 and revised on 11/07/2025.
Interventions included 10/7/25: Fall Risk: *Bolster / Scoop Mattress for safe boundaries to minimize risk for rolling out of bed., date initiated, created, and revised 10/07/2025. During an observation and interview on 11/07/2025 at 01:21 p.m., Resident #1 was observed lying on bed with an air mattress with bolsters and his call light in reach. Resident #1 stated he had a fall at the facility. He stated he slipped out of bed but did not get hurt. He stated he did not need to be sent out to the hospital. During an interview on 11/10/2025 at 02:59 p.m., the RNAC stated the procedure for her knowing if a resident had a fall was to attend the interdisciplinary team meetings in the morning and to review the risk management reports. She stated a resident having had a miscoded fall history on his MDS assessment would not impact his care if the fall was care-planned with appropriate interventions. She stated for Resident #1, she coded there was no falls, but he did have a fall according to a risk management report. She stated this error would not have impacted Resident #1's care because the staff provide care according to the resident's care plan. During an interview
on 11/10/2025 at 04:30 p.m., the DON stated a documentation error on the fall history of a MDS assessment would not impact a resident's care if the interventions for the fall was care-planned. During an
interview on 05/16/2025 at 04:46 p.m., the ADMIN stated there would be no impact on a resident's care if
the MDS assessment's fall history was incorrect, if the care plan was accurate. She stated if the care plan was accurate, the team providing direct care to the resident would be aware of the interventions enacted following the fall. Record review of the facility's policy, Comprehensive Assessments, dated revised March 2023, reflected: .Accuracy of AssessmentEach resident receives an accurate team member assessment of relevant care areas that provide teammembers [sic] with knowledge of each resident's status, needs, strengths, and areas of decline.CertificationA registered nurse signs and certifies that the assessment is completed. Everyone who completes aportion [sic] of the assessment also signs and certifies the accuracy of that portion of the assessment. MDS information is the clinical basis for each resident's care planning and delivery. Each individual assessor is responsible for certifying the accuracy of responses on the forms relative to the resident'scondition [sic] and discharge or reentry status.
Event ID:
Facility ID:
If continuation sheet
STONE OAK CARE CENTER in SAN ANTONIO, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 SAN ANTONIO, 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 STONE OAK CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.