Stone Oak Care Center
505 Madison Oak Dr · San Antonio, TX · 78258 · 2104819000
152 certified beds For profit - Limited Liability company Chain: Touchstone Communities
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection results are getting worse cycle over cycle, not better.
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Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
RN staffing in the bottom 10% nationally
0.28 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Total nurse staffing below 3.0 hours per resident-day
2.86 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
61% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 2.86 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.28 | 0.55–0.75 |
| Weekend hours / resident-day | 2.50 | ≈ weekday level |
| Nursing turnover / year | 61% | median 45% |
| Fines (3-yr window) | 1 · $9,087 |
Inspection citations (41 in the current record)
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Potential for harm · D December 3, 2025 · found via complaint
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected December 4, 2025 · Nursing and Physician Services
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Potential for harm · D December 3, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 4, 2025 · Pharmacy Service
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Potential for harm · D December 3, 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 December 4, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 3, 2025 · found via complaint
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected December 4, 2025 · Administration
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Potential for harm · D November 25, 2025 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected November 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 20, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected November 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 20, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 21, 2025 · Pharmacy Service
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Potential for harm · D November 20, 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 November 21, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 20, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected November 21, 2025 · Infection Control
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Potential for harm · D July 25, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected July 26, 2025 · Resident Rights
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Potential for harm · D July 25, 2025
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected July 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · E July 25, 2025
Ensure each resident receives an accurate assessment.
Corrected July 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 25, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected July 26, 2025 · Quality of Life and Care
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Potential for harm · D July 25, 2025
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected July 26, 2025 · Nursing and Physician Services
-
Potential for harm · E July 25, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected July 26, 2025 · Pharmacy Service
-
Potential for harm · E July 25, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 26, 2025 · Nutrition and Dietary
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Potential for harm · D July 25, 2025
Provide and implement an infection prevention and control program.
Corrected July 26, 2025 · Infection Control
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Immediate jeopardy · J June 27, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 27, 2025 · Quality of Life and Care
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Potential for harm · D June 27, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 27, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 27, 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 June 28, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 21, 2024
Ensure each resident receives an accurate assessment.
Corrected June 22, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 21, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected June 22, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 21, 2024
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected June 22, 2024 · Quality of Life and Care
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Potential for harm · D June 21, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 22, 2024 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 27, 2025 | Fine | $9,087 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 675968 · certified since May 13, 2003. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.