Stone Oak Care Center

Name: Stone Oak Care Center
Address: 505 Madison Oak Drive, San Antonio, TX, 78258, US
Telephone: 2104819000

505 Madison Oak Drive, San Antonio, TX 78258 · Bexar County · 152 certified beds · avg 125 residents/day · certified since May 13, 2003

Part of chain: TOUCHSTONE COMMUNITIES (25 facilities, chain avg rating 2.9★)

3/5

Health inspection rating (on-site)

Serious findings on record

$9,087

Fines, last 3 years

2.60

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jun 27, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jun 27, 2025 (Past Non-Compliance)

All citations in the current public record (40)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 4, 2026	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Dec 3, 2025	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Dec 3, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Dec 3, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Dec 3, 2025	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint
Nov 25, 2025	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jul 25, 2025	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jul 25, 2025	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jul 25, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 25, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jul 25, 2025	D · Potential for harm, one-off	The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Jul 25, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jul 25, 2025	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jul 25, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 27, 2025	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 27, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jun 27, 2025	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jun 27, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jun 21, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 21, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 21, 2024	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Jun 21, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jun 21, 2024	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jun 21, 2024	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 21, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Sep 22, 2023	D · Potential for harm, one-off	The facility did not provide routine dental care and 24-hour emergency dental care for residents. · from a complaint
Apr 28, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 28, 2023	E · Potential for harm, repeated	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 28, 2023	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 28, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 28, 2023	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 28, 2023	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Apr 28, 2023	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Apr 28, 2023	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Apr 28, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Apr 28, 2023	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (7 → 8).

Year	Citations	Serious (G–L)	Worst severity that year
2023	11	0	F
2024	7	0	D
2025	21	1	J ▲
2026	1	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $9,087.

Date	Type	Amount / length
Jun 27, 2025	Fine	$9,087

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.60	3.46	3.95	bottom 5% in Texas; bottom 5% in the U.S.
Registered Nurse hours	0.21	0.44	0.69	bottom 8% in Texas; bottom 3% in the U.S.
Weekend total nurse staffing	2.24	3.04	3.50	bottom 5% in Texas; bottom 4% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.11	0.34	0.48	bottom 3% in Texas; bottom 2% in the U.S.
Total nursing staff turnover (%)	59.8	55.3	45.8	bottom 33% in Texas; bottom 17% in the U.S.
RN turnover (%)	69.2	54.6	42.9	bottom 30% in Texas; bottom 12% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.88, RN 0.23, weekend 2.48. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Bexar County Hospital District	Organization	5% or Greater Direct Ownership Interest	100%	03/01/2016
Aegis Therapies, INC.	Organization	ADP of the SNF	NOT APPLICABLE	03/01/2016
Basaldua, Rolando	Individual	Operational/Managerial Control	NOT APPLICABLE	11/24/2025
Basaldua, Rolando	Individual	ADP of the SNF	NOT APPLICABLE	11/24/2025
Campbell, Leslie	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2020
Campbell, Leslie	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2020
Carvajal Pharmacy LTC	Organization	ADP of the SNF	NOT APPLICABLE	03/01/2016
Castaneda, Monica	Individual	Operational/Managerial Control	NOT APPLICABLE	06/06/2023
Castaneda, Monica	Individual	ADP of the SNF	NOT APPLICABLE	06/06/2023
Castillo, Lynnea	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2016
Castillo, Lynnea	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2016
Clayton, Jonathon	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2023
Clayton, Jonathon	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2023
Fellbaum, Ernest	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2016
Givens, Laura	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2022
Hurley, Christopher	Individual	Corporate Officer	NOT APPLICABLE	09/26/2014
International Bank of Commerce	Organization	5% or Greater Security Interest	NOT APPLICABLE	04/16/2018
Nutritious Lifestyles, INC.	Organization	ADP of the SNF	NOT APPLICABLE	03/01/2016
Plante & Moran PLLC	Organization	ADP of the SNF	NOT APPLICABLE	03/01/2016
Sehlke, Bryon	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2016

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you keep residents' medical records accurate, complete, and secure?"
"How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"How do you coordinate hospice care, and can residents stay here while receiving it?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Sonterra Health Center	0.5 mi	San Antonio, TX	★☆☆☆☆	2/5
Coronado at Stone Oak	0.8 mi	San Antonio, TX	★★★★★	4/5
The Enclave	1.1 mi	San Antonio, TX	★☆☆☆☆	2/5
Estates at Shavano Park	5.2 mi	Shavano Park, TX	★★★☆☆	3/5
Castle Hills Rehabilitation and Care Center	5.9 mi	San Antonio, TX	★☆☆☆☆	1/5
San Antonio Wellness & Rehabilitation	7.3 mi	San Antonio, TX	★★☆☆☆	2/5
Broadway Nursing & Rehabilitation	7.7 mi	San Antonio, TX	★☆☆☆☆	2/5
The Heights on Huebner	8.0 mi	San Antonio, TX	★★★★☆	4/5
The Heights at Medical Center	8.1 mi	San Antonio, TX	★☆☆☆☆	2/5
Patriot Heights Health Care Center	8.4 mi	San Antonio, TX	★★☆☆☆	2/5	abuse
The Lev at San Antonio	8.5 mi	San Antonio, TX	★☆☆☆☆	2/5
Sage Park San Antonio	8.6 mi	San Antonio, TX	★★★☆☆	2/5

Compare this facility with the 3 closest →

All facilities in San Antonio →

Facility data as of CMS processing date 2026-08-01. CCN 675968.

The Care File

Visit checklist — Stone Oak Care Center

505 Madison Oak Drive, San Antonio, TX 78258 · 2104819000

Health inspection rating 3/5 · CMS overall 2/5· Fines (3y): $9,087

Most serious findings on record:

▲ Jun 27, 2025 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "How do you coordinate hospice care, and can residents stay here while receiving it?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 675968 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)