Sonterra Health Center
18514 Sonterra Place · San Antonio, TX · 78258 · 2105454800
124 certified beds Government - Hospital district Chain: The Ensign Group Hospital-based
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $80,964 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
Red flags
3 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$80,964 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.66 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.39 | 0.55–0.75 |
| Weekend hours / resident-day | 3.04 | ≈ weekday level |
| Nursing turnover / year | 48% | median 45% |
| Fines (3-yr window) | 3 · $80,964 |
Inspection citations (50 in the current record)
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Actual harm · G May 15, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected June 13, 2025 · Resident Rights
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Actual harm · G May 15, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected June 13, 2025 · Quality of Life and Care
-
Potential for harm · D May 15, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected June 13, 2025 · Resident Rights
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Potential for harm · D May 15, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected June 13, 2025 · Resident Rights
-
Potential for harm · D May 15, 2025
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected June 13, 2025 · Resident Rights
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Potential for harm · D May 15, 2025
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected June 13, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 15, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected June 13, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 15, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected June 13, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 15, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 13, 2025 · Quality of Life and Care
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Potential for harm · D May 15, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 13, 2025 · Quality of Life and Care
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Potential for harm · D May 15, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected June 13, 2025 · Quality of Life and Care
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Potential for harm · D May 15, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected June 13, 2025 · Pharmacy Service
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Potential for harm · D May 15, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected June 13, 2025 · Pharmacy Service
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Potential for harm · D May 15, 2025
Provide and implement an infection prevention and control program.
Corrected June 13, 2025 · Infection Control
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Potential for harm · D May 15, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 13, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 15, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 13, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 25, 2025 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected April 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 25, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected May 16, 2025 · Resident Assessment and Care Planning
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Immediate jeopardy · J March 21, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected March 17, 2025 · Pharmacy Service
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Potential for harm · D March 21, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 24, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 14, 2024 · found via complaint
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected September 15, 2024 · Pharmacy Service
-
Immediate jeopardy · J August 14, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 15, 2024 · Resident Assessment and Care Planning
-
Immediate jeopardy · J August 14, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 15, 2024 · Quality of Life and Care
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Potential for harm · E June 14, 2024 · found via complaint
Post nurse staffing information every day.
Corrected June 15, 2024 · Nursing and Physician Services
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Potential for harm · E June 14, 2024 · found via complaint
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected June 15, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 25, 2025 | Fine | $17,345 |
| March 21, 2025 | Fine | $14,901 |
| August 14, 2024 | Fine | $48,718 |
| August 14, 2024 | Payment Denial | 2 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676158 · certified since November 28, 2007. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.