Stone Oak Care Center
STONE OAK CARE CENTER in SAN ANTONIO, TX — inspection on November 25, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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