Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sonterra Health Center during CMS and state inspections, most recent first.
The facility did not consistently conduct timely and comprehensive care plan reviews for two residents, missing several required quarterly reviews and failing to ensure the participation of residents and their representatives. The Director of Social Services acknowledged missed meetings due to lack of a formal schedule, and staff interviews confirmed that care plan meetings were not held regularly, despite the facility's policy assigning responsibility for scheduling to the MDS Coordinator.
A resident with cognitive impairment and risk factors for skin breakdown did not have weekly skin assessments documented as required by facility policy. Although the MAR indicated assessments were completed, actual documentation was missing for most weeks, and staff interviews confirmed the assessments were not consistently performed or recorded.
A resident with diabetes was not administered prescribed insulin for two days, leading to hospitalization for Diabetic Ketoacidosis. The facility failed to transcribe hospital discharge orders into the electronic medical record, resulting in a significant medication error. Staff interviews revealed that the admitting nurse may have missed a page of the orders, and the oversight was discovered when the resident felt unwell.
A resident with diabetes and other health conditions experienced a medication error when insulin orders were not transcribed, leading to hyperglycemia and hospitalization. The facility failed to report this neglect to the State Survey Agency as required by policy.
A medication security lapse occurred when a blister package of Tamulosin HCL was left unattended on a medication cart in the 400 hall. The medication, prescribed for a resident with Benign Prostatic Hypertrophy, was accessible to anyone passing by, as the cart was left at the end of the hall without a nurse in sight. RN A admitted the oversight, and both the DON and Administrator confirmed that medications should be stored securely inside the cart or medication room, as per facility policy.
Two residents with cognitive impairments and dysphagia were not provided with the necessary assistance during meals as outlined in their care plans. One resident was left unsupervised and choked, resulting in death, while another was observed eating unassisted despite requiring substantial help. Staff interviews revealed a lack of familiarity with care plans, leading to inconsistent care and placing residents at risk.
A resident with a history of dementia and dysphagia was left unsupervised during a meal, leading to choking and subsequent death. Despite requiring assistance with eating, the resident was found in distress with a piece of broccoli obstructing his airway. Staff interviews revealed confusion about supervision protocols, contributing to the incident.
The facility did not post daily nurse staffing information as required, with observations revealing outdated postings. The responsibility for updating this information was not delegated during the scheduling coordinator's absence, leading to a lack of accessible staffing data for residents and visitors.
The facility failed to secure medication carts, leaving them unlocked and unsupervised, with approximately 450 pills exposed. An LVN admitted to leaving the carts unattended due to workload. The ADON and Administrator acknowledged the risk of potential harm to residents from unsecured medications, which violated the facility's policy.
The facility failed to label sandwiches with preparation and expiration dates, as observed during a survey. A sandwich was found unmarked on a snack cart, and a CNA confirmed it was unsafe to serve without labeling. The Food Service Manager stated that all snacks should be labeled, aligning with the facility's policy and FDA guidelines.
The facility failed to ensure accurate MDS assessments for five residents, leading to deficiencies in their care plans. Errors included not reflecting hospice services, incorrect documentation of pressure sores, and inaccurate bowel and bladder incontinence status. Both MDS staff and the DON acknowledged the importance of accurate assessments for proper care.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident's fall prevention measures were not properly implemented, another resident's incontinence was not accurately reflected in the care plan, and a third resident's hospice status was not included in the care plan.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. Interviews and record reviews revealed multiple days without RN coverage between November and December 2023. The DON and scheduler could not provide evidence of RN coverage on the specified dates, leading to the deficiency report.
The facility failed to store, prepare, distribute, and serve food safely. Insulated plate lids and bases were not air-dried, leading to potential cross-contamination. Additionally, a cook tasted food with a bare finger and continued using the same equipment, risking contamination.
A resident's care plan was not updated to reflect his NAS regular texture diet, despite active orders and meal tickets indicating this diet. The discrepancy between the care plan and the resident's actual dietary needs was confirmed by staff, potentially affecting the resident's quality of life.
The facility failed to provide proper incontinent care for a resident, as CNA C did not return the foreskin to its original position after cleaning. Both CNAs involved acknowledged their mistake despite being trained to reposition the foreskin. The resident's care plan did not reflect his incontinence, and the DON confirmed the importance of proper care to prevent complications.
Failure to Conduct Timely and Comprehensive Care Plan Reviews
Penalty
Summary
The facility failed to prepare and maintain comprehensive care plans for two residents, as required. Specifically, the care plans were not reviewed and revised quarterly following each assessment, and the participation of the residents and their representatives was not consistently included to the extent practicable. For one resident with severe cognitive impairment and a history of muscle wasting, urinary tract infections, and mild cognitive impairment, quarterly care plan reviews were missed in two out of five required periods. For another resident with epilepsy, a history of falls, and hypertensive heart disease, three out of six quarterly care plan reviews were missed. Interviews revealed that the residents' representatives were not regularly involved in care plan meetings, with one stating she could not recall recent participation and another having to request a meeting. The Director of Social Services acknowledged that care plan review meetings were missed and attributed this to a lack of a formal schedule, stating that she was attempting to catch up on overdue assessments. The facility's policy indicated that the MDS Coordinator was responsible for scheduling and preparing the care plan meeting calendar, but no updated policy on regular care plan meetings was provided upon request. The DON and Administrator confirmed that issues with the regularity of care plan meetings had been identified previously. Documentation showed that the facility had discussed care plan meeting processes in a QAPI meeting, but gaps in care plan reviews persisted for the residents involved.
Failure to Document Weekly Skin Assessments per Facility Policy
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for one resident reviewed for record accuracy. Specifically, the facility did not ensure that weekly skin evaluations were documented as required by facility policy for six out of seven weeks during a specified period. Although the Medication Administration Record (MAR) indicated that weekly skin evaluations were marked as completed, a review of the actual assessment documentation revealed that these evaluations were not performed or recorded for the majority of the required dates. Interviews with nursing staff and the Director of Nursing (DON) confirmed that weekly skin assessments were not conducted or documented during the months in question. The resident involved was an elderly female with a history of muscle wasting, urinary tract infections, and mild cognitive impairment, and was identified as being at risk for pressure ulcer development. The resident's care plan included interventions for monitoring skin integrity, and facility policy required weekly skin and wound assessments by a licensed nurse. Despite these requirements, the necessary documentation was missing, and staff interviews indicated a lack of consistent practice and understanding regarding the completion and documentation of weekly skin assessments.
Failure to Administer Insulin Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of insulin. The resident, a male with a history of diabetes type 1, renal dialysis dependence, and hypertension, was not administered his prescribed insulin medications, Touch U-200 and Novo Log, for two days. This lapse occurred from March 12 to March 14, 2025, leading to the resident being sent to the hospital and diagnosed with Diabetic Ketoacidosis, a serious complication of diabetes. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The resident's hospital discharge instructions included orders for insulin administration, which were not transcribed into the facility's electronic medical record system. This oversight was discovered when the resident expressed feeling unwell, prompting a family member to inquire about the insulin administration. The Licensed Vocational Nurse (LVN) on duty confirmed the omission and reported it to the Assistant Director of Nursing (ADON). Interviews with the facility's nursing staff revealed that the admitting nurse may have missed a page of the admission orders, leading to the medication error. The ADON and Director of Nursing (DON) acknowledged the failure to transcribe the insulin orders and emphasized the importance of following policy and procedure regarding medication administration. The Medical Director was informed of the missed insulin orders but was not initially concerned due to the long-acting nature of the insulin. However, the failure to administer the insulin as prescribed placed the resident at risk for severe health complications.
Failure to Report Medication Error and Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency as required by their policy. This incident involved a medication error where a resident's insulin orders were not transcribed, leading to the resident experiencing hyperglycemia and being sent to the emergency room for evaluation. The resident, who was dependent on renal dialysis and had diabetes and hypertension, was admitted to the hospital with diabetic ketoacidosis, a serious complication of diabetes. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) discovered the error after the resident expressed feeling unwell and a family member inquired about the insulin administration. The Assistant Director of Nursing (ADON) was informed but did not report the incident to the State Survey Agency. The Director of Nursing (DON) and the Administrator were also aware of the incident but did not report it, believing the issue was corrected. However, upon reviewing the neglect guidelines, the Administrator acknowledged the need to report the incident.
Medication Security Lapse on 400 Hall
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, as observed with the 400 hall medication cart. A blister package of Tamulosin HCL, prescribed for a resident with Benign Prostatic Hypertrophy, was found on top of the medication cart, unattended. The cart was located at the end of the hall with no nurse in sight, allowing anyone passing by to potentially access the medication. This oversight was acknowledged by RN A, who admitted the medication should have been secured in the cart but was left out due to a hectic night. Interviews with the Director of Nursing (DON) and the Administrator confirmed that medications should be stored inside the medication cart or in the medication room, not left on top of the cart. Both emphasized the responsibility of the nursing staff, particularly the nurse with the keys, to ensure medications are secured. The facility's Medication Access and Storage Policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. The failure to adhere to this policy was evident in the incident involving the 400 hall medication cart.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, leading to significant deficiencies in their care. Resident #1, who had a history of dementia, dysphagia, and other cognitive impairments, required assistance with eating as per his care plan. However, on the evening of the incident, he was left unsupervised in his room during a meal, resulting in a choking incident. Despite efforts by staff to assist him, including performing the Heimlich maneuver and calling emergency services, Resident #1 was pronounced deceased at the facility. Resident #2, who had severe cognitive impairment and dysphagia, also required assistance with eating according to her care plan. Observations revealed that she was left to eat unassisted on multiple occasions, despite her care plan indicating she needed substantial assistance. Staff interviews indicated a lack of awareness and understanding of the care plans, with some staff members not knowing how to access or interpret the care plans and Kardex, leading to inconsistent care. The deficiencies in care for both residents were compounded by a lack of communication and training among staff regarding the residents' care plans. Interviews with staff revealed that many were not familiar with the care plans or the requirement to review them, resulting in inadequate supervision and assistance during meals. This failure to adhere to the care plans placed residents at risk for weight loss, malnutrition, and dehydration.
Inadequate Supervision During Meal Leads to Resident's Death
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during the evening meal, leading to a tragic incident. The resident, who had a history of dementia, dysphagia, and other conditions affecting swallowing and coordination, was left unsupervised in his room. Despite requiring assistance with eating, the resident was found choking and later pronounced deceased. Staff interviews revealed confusion and inconsistency regarding the supervision requirements for residents needing assistance with meals. The resident's care plan and assessments indicated a need for staff assistance with eating due to risks of aspiration and difficulty swallowing. However, during the incident, the resident was left alone, and staff were not immediately available to provide the necessary assistance. The resident was found in distress, with secretions and a piece of broccoli obstructing his airway. Despite efforts to clear the obstruction and provide emergency care, the resident did not survive. Interviews with staff highlighted a lack of clear communication and understanding of the facility's protocols for supervising residents during meals. Some staff believed they could leave the resident unattended if they only required assistance, while others understood that constant supervision was necessary. This inconsistency contributed to the failure to provide the required supervision, ultimately leading to the resident's death.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, which is a requirement to ensure transparency and accessibility of staffing data to residents and visitors. During an observation, it was noted that the facility's Daily Nursing Care Hours posting was outdated, displaying information from two days prior. This deficiency was confirmed through interviews with the Assistant Director of Nursing (ADON) and the Administrator, who acknowledged that the posting should be updated daily. The Administrator further explained that the responsibility for generating and posting this information fell to CNA D, the scheduling coordinator, who did not delegate the task during their scheduled time off. The facility's policy, dated May 2007, mandates that nurse staffing data be posted daily in a clear and readable format in a prominent location accessible to residents and visitors. The failure to adhere to this policy was attributed to a lack of coordination in the staffing process, particularly when the designated staff member was unavailable. This oversight could potentially deny residents and visitors access to important staffing information, as the data was not updated as required.
Unsecured Medication Carts in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by their policy. During an observation, it was noted that the 100-hall medication aide cart, the nurse medication cart, and the treatment cart were left unlocked and unsupervised. These carts were positioned at the end of the 100-hall, out of the line of sight of the nurse, LVN A, who was seated at the nurses' station documenting at the computer. One of the medication carts had approximately 15 medication cards on top, each containing about 30 pills, totaling an estimated 450 pills, which were unsecured. Interviews with LVN A, the Assistant Director of Nursing (ADON), and the Administrator confirmed that the medication carts should have been locked whenever unattended. LVN A admitted to the bad habit of leaving the carts unlocked due to having responsibilities for two halls. The ADON and the Administrator both acknowledged the risk of potential harm to residents due to unsecured and uncontrolled medications. A review of the facility's Medication Access and Storage policy from May 2007 reiterated that all drugs and biologicals should be stored in locked compartments, accessible only to authorized personnel.
Failure to Label Prepared Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling sandwiches with preparation and expiration dates. During an observation, a sandwich was found wrapped in clear plastic cling wrap and stored at room temperature on a snack cart without any labeling. This lack of labeling was confirmed by a CNA, who stated that the sandwich was not safe to serve due to the absence of information regarding its preparation date and expiration. The Food Service Manager acknowledged that all snacks prepared by the kitchen should have been labeled with the date of preparation and the date by which they should no longer be served. A review of the facility's Food Preparation and Storage policy indicated that food items should be properly dated and labeled, and any unmarked or unlabeled foods should be discarded after three days. The United States Food and Drug Administration's 2022 Food Code also requires that ready-to-eat, time/temperature control for safety food prepared and held for more than 24 hours be clearly marked with a date to ensure safety.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate assessments for five residents, leading to deficiencies in their care plans. Resident #6's quarterly MDS assessment did not reflect that the resident was receiving hospice services, despite physician orders and a comprehensive care plan indicating hospice care. Similarly, Resident #17's significant change MDS assessment failed to document hospice services, even though the resident had been receiving hospice care since early March. Both MDS A and MDS B acknowledged the errors and emphasized the importance of accurate coding to trigger appropriate care plans. Resident #19's quarterly MDS assessment inaccurately reflected her pressure sore status, interventions, and treatments, despite having a Stage 3 pressure sore with documented interventions and treatments. The MDS assessment failed to capture these critical details, which are essential for guiding and communicating care needs to staff. MDS A admitted to not knowing how these details were missed, and the DON highlighted the importance of accurate MDS assessments for ensuring proper care. Resident #53's quarterly MDS assessment inaccurately documented bowel and bladder incontinence, stating the resident was frequently incontinent when he was always incontinent. Observations and interviews confirmed the resident's total dependence on bowel and bladder care. Similarly, Resident #67's admission MDS assessment incorrectly marked him as always incontinent of bladder instead of not rated due to an indwelling urinary catheter. Both MDS A and the DON acknowledged the inaccuracies and stressed the need for accurate MDS assessments to reflect the residents' conditions and guide their care plans effectively.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #19, who had a history of falls and was severely cognitively impaired, required a floor mat beside her bed as a fall prevention measure. However, observations revealed that the floor mat was not properly placed, and staff were unaware of its incorrect placement, potentially putting the resident at risk of falls. Interviews with the CNA and DON confirmed the oversight and the importance of the intervention for the resident's safety. Resident #53, who was cognitively intact but frequently incontinent of bowel and bladder, did not have his incontinence accurately reflected in his comprehensive care plan. Despite being dependent on bowel and bladder care, his care plan only mentioned the need for assistance with toilet use. Observations and interviews with the resident and staff confirmed that he was always incontinent and did not use the toilet, urinal, or bedpan, highlighting a significant gap in his care plan. Resident #127, who was moderately cognitively impaired and dependent on staff for ADLs, was admitted to hospice services with a terminal diagnosis of cardiovascular accident. However, his comprehensive care plan did not reflect his hospice status. Interviews with the MDS coordinator and DON confirmed that the care plan should have been updated to include hospice services, emphasizing the importance of accurate care plans for effective communication and care delivery.
Failure to Ensure RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to ensure the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage for 8 hours on multiple days between November 4, 2023, and December 15, 2023. Specifically, the facility lacked RN coverage on 11/04/23, 11/05/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/07/23, and 12/15/23. The Director of Nursing (DON) confirmed the absence of RN coverage on these dates and stated that the facility had a scheduler responsible for ensuring RN coverage. However, the scheduler did not provide evidence of RN coverage on the specified dates. Interviews with the DON and the scheduler revealed that the DON worked Monday to Friday for 8 hours a day and covered weekends if RN hours were not covered. The DON was also on-call when there was no RN on duty. The scheduler, a Certified Nursing Assistant (CNA), stated that she scheduled RN coverage for at least 8 hours per day but could not recall any day without RN coverage in November or December 2023. The facility administrator confirmed that there was no policy regarding RN coverage but stated that the facility followed the State Operations Manual (SOM) and Texas Administrative Code (TAC) regarding RN hour regulation. Despite these assertions, there was no evidence provided to confirm RN coverage on the specified dates, leading to the deficiency report.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility did not ensure that insulated plate lids and bases were air-dried before being stacked, leading to water droplets remaining on them. This was observed when DA J took the washed insulated plate lids and bases from the dishwashing machine and stacked them on a cart without allowing them to air dry. Later, during lunch meal service, DA J placed these wet lids and bases over and under plates, which could potentially cause cross-contamination. Both DA J and the DS acknowledged that this practice could lead to foodborne illness due to cross-contamination from the water droplets. Additionally, the facility failed to ensure that Cook I prepared pureed pasta salad in a sanitary manner. Cook I was observed tasting the pasta salad with his bare finger and then continuing to use the same equipment without washing it, which he admitted could contaminate the food. The DS confirmed that this action constituted cross-contamination and could make residents sick. The facility's policies on cleaning dishes and employee sanitary practices were not followed, as dishes were not allowed to air dry, and clean spoons were not used for tasting food.
Failure to Update Resident Care Plan for Dietary Needs
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for a resident diagnosed with dementia, syncope, dysphagia, and weakness. The resident's care plan was not updated to reflect that he was on a no added salt (NAS) regular texture diet, despite his active orders and meal tickets indicating this diet. The resident's quarterly MDS assessment indicated he was severely cognitively impaired and required setup assistance for eating, but his care plan still listed a mechanical soft texture diet. Observations and interviews revealed that the resident consistently received a regular texture diet, and staff were aware of this requirement. However, the care plan was not updated accordingly, which was confirmed by the MDS coordinator and the Director of Nursing (DON). The failure to update the care plan after the quarterly MDS assessment in January led to a discrepancy between the care plan and the resident's actual dietary needs, potentially affecting the resident's quality of life.
Failure to Provide Proper Incontinent Care for Resident
Penalty
Summary
The facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. During an observation, CNA C did not return the foreskin of Resident #53 to its original position after cleaning his penis during incontinent care. This action was contrary to the facility's policy and procedure for perineal care, which requires the foreskin of an uncircumcised male to be repositioned after cleaning. Both CNA C and CNA D, who assisted in the care, acknowledged their mistake and confirmed they were trained to reposition the foreskin but failed to do so during the incident. Resident #53, who is cognitively intact with a BIMS score of 15/15, has diagnoses including epilepsy, unsteadiness on feet, repeated falls, weakness, and other malaise. His comprehensive care plan did not reflect his incontinence of bowel and bladder, only noting his need for assistance with ADLs due to epilepsy. The Director of Nursing (DON) confirmed the importance of repositioning the foreskin to prevent complications such as infection and impaired blood circulation. Competency checklists for both CNAs indicated they had satisfactorily completed training for incontinent care, including repositioning the foreskin.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stone Oak Care Center | 0.5 mi | ★★★★★ | 9 | 0 |
| The Enclave | 1.2 mi | ★★★★★ | 20 | 0 |
| Coronado At Stone Oak | 1.3 mi | ★★★★★ | 2 | 0 |
| Estates At Shavano Park | 4.9 mi | ★★★★★ | 20 | 0 |
| Castle Hills Rehabilitation And Care Center | 5.4 mi | ★★★★★ | 52 | 1 |
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