Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the rights to reside and receive
services in the facility with reasonable accommodation of resident needs and preferencesfor 2 of 28
residents (Resident #47 and Resident #50) reviewed for resident rights, in that:
Residents Affected - Few
Facility did not ensure the automated handicap push button, at the front lobby, to exit the facility allowed
residents to easily exit the facility, while in a wheelchair.
This deficient practice could place residents at risk for bodily injury while attempting to leave the facility by
pushing the automated handicap button.
The findings were:
Record review of Resident #47's face sheet, dated 02/17/2023, revealed the resident was admitted to the
facility on [DATE] with diagnoses that included: spinal stenosis, anxiety, asthma, shortness of breath, and
recurrent depressive disorder.
Record review of Resident #47's quarterly MDS, dated [DATE], revealed the resident had a BIMS of 10,
which indicated the resident was moderate cognitive impairment.
Record review of Resident #50's face sheet, dated 02/17/2023, revealed the resident was admitted to the
facility on [DATE] with diagnoses that included: anxiety, major depressive disorder, and stage 5 chronic
kidney disease.
Record review of Resident #50's quarterly MDS, dated [DATE], revealed the resident had a BIMS of 15,
which indicated the resident was intact cognitive impairment.
During the resident group meeting on 02/15/2023 at 1:45 p.m., Resident #47 and Resident #50 stated that
the automatic handicap button was not releasing the front door.
During an observation and interview on 02/15/2023 at 6:00 p.m., revealed when the handicap button was
pushed, to go out front, the front door did not automatically open. However, the front door made noises that
it tried to open but something kept the door from automatically opening. The Maintenance Director stated
the panic bar reengaged when the door came back after depressing the automatic actuator button which
prevented the one releasing action required to open the front Lobby Exit door and he stated the panic bar
probably needed to be replaced and would immediately fix the exit door. He further stated he was not
aware that the front door was supposed to automatically open, without pushing the panic bar, after pushing
the handicap button.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
676353
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676353
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coronado at Stone Oak
19638 Stone Oak Parkway
San Antonio, TX 78258
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 02/17/2023 at 2:51 p.m., Resident #50 stated he was stuck in the doorway upfront
because the automatic handicap button did not release correctly. He stated it was early in the morning
around 4 am and there was no one to tell. Resident #50 stated he felt helpless and had to wait for someone
to come and help him. He was not able to recall how long ago this happened or how long it took for
someone to come help him. Resident #50 stated he was not able to recall how long the handicap button
was not working but knew it had been a long while since it did.
During an interview on 02/17/2023 at 2:54 p.m., Resident #47 stated he was not able to remember how
long the handicap button at the front door had not worked. He stated he feels helpless because that door is
heavy and hard to open. Resident #47 stated he told the administrator at some point about it but was
unable to remember how long ago he told him.
During an interview on 02/17/2023 at 3:38 p.m., the DON stated she was not aware that the automated
handicap button at the front door was not working properly. She stated the Maintenance Director was
responsible for ensuring it worked correctly. The DON was not able to recall if it worked while she was at
this facility. She stated she did not believe there was a potential harm to residents with the button not
working.
During an interview on 02/17/2023 at 3:58 p.m., the Administrator stated he was not aware that the
automated handicap button at the front door was not working properly. He further stated he was not aware
of why it was not working properly. The Administrator stated he did not believe there was a potential harm to
residents with the button not working.
Record review of the facility's policy titled, Resident Rights, revised 02/2021, revealed Federal and state
laws guarantee certain basic rights to all residents of this facility. These rights included the resident's rights
to: a. a dignified existence; b. be treated with respect, kindness, and dignity; [ .] e. self-determination; f.
communication with and access to people and services, both inside and outside the facility; [ .] i. exercise
his or her rights without interference, coercion, discrimination, or reprisal from the facility.
Record review of the facility's policy titled, Environmental/Safety, dated 01/2016, revealed 1.
Environmental/safety monitoring tasks must be performed in accordance with the Environmental/Safety
Monitoring Protocol.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676353
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676353
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coronado at Stone Oak
19638 Stone Oak Parkway
San Antonio, TX 78258
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to coordinate assessments with the pre-admission screening
and resident review (PASARR) program, and failed to refer all residents with possible serious mental
disorder for level II resident review for 1 (Resident #30) of 26 residents reviewed for PASARR program, in
that:
Resident #30 had a serious mental disorder and was not referred for level II review.
This failure could result in residents with serious mental disorders not receiving support services.
The findings were:
Record review of Resident #30's face sheet, dated 02/17/2023, revealed the resident was admitted on
[DATE] with diagnoses including: schizoaffective disorder bipolar type, generalized anxiety disorder, and
pain unspecified.
Record review of Resident #30's comprehensive MDS, dated [DATE], revealed a BIMS score of 15 which
indicated intact cognition. [Resident #30] ineffective individual coping [related to] inability to manage
internal and external stressors secondary to anxiety, depression, and schizophrenia. [Resident #30]
currently takes anti-depressant, anti-anxiety, and anti-psychotic medication.
Record review of Resident #30's physician orders as of 02/15/2023, revealed she had been prescribed
Prozac for Generalized Anxiety Disorder, Buspirone for Generalized Anxiety Disorder, and Zyprexa for
Schizoaffective Disorder Bipolar Type.
Record review of Resident #30's PASARR Level I screening tool revealed, Is there evidence or an indicator
this is an individual that has a Mental Illness? No.
During an interview with LVN/MDS A on 02/17/2023 at 10:17 a.m., LVN/MDS A stated that Resident #30's
PASARR Level I was incorrect when it was received by the facility, and should have been corrected by
facility staff, but the incorrect PASSARR Level 1 was not found by facility staff. LVN/MDS A further stated
that Resident #30 had not been referred to the local mental health authority for evaluation and should have
been. LVN/MDS A confirmed that Resident #30 may have been eligible to receive specialized support
services from the local mental health authority, if Resident #30 had been referred to the authority. LVN/MDS
A stated she was responsible for ensuring PASARR documentation was complete and correct
During an interview with the DON on 02/17/2023 at 2:17 p.m., the DON stated the MDS Department or SW
are responsible for ensuring that PASARR documentation is complete and correct. The DON confirmed that
Resident #30 may have been eligible to receive specialized support services from the local mental health
authority, if Resident #30 had been referred to the authority.
Record review of the facility policy, Assessments, dated November 2017, revealed, .Upon admission, each
Patient/Resident's diagnoses must be reviewed with the physician to develop individualized care plan
interventions . The care plan must include . PASRR recommendations if applicable. In addition,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676353
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676353
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coronado at Stone Oak
19638 Stone Oak Parkway
San Antonio, TX 78258
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
the facility must provide or obtain the required services . to provide any rehabilitative services . for mental
disorders .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676353
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676353
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coronado at Stone Oak
19638 Stone Oak Parkway
San Antonio, TX 78258
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to collaborate with hospice representatives and coordinate the
hospice care planning process for each resident receiving hospice services, to ensure quality of care for the
resident, ensuring communication with the hospice medical director, the resident's attending physician, and
others participating in the provision of care for 3 of 6 residents (Resident #55, Resident #53, and Resident
#22) reviewed for hospice services, in that:
1. Facility did not ensure Resident #55's Certification of Terminal Illness form was in the resident's records
2. Resident #53's Hospice Election form was completed incorrectly, the Certification of Terminal Illness form
was missing, and the Hospice Plan of Care had expired.
3. Facility did not ensure Resident #22's hospice election form was in the resident's records
This deficient practice could place residents who receive hospice services at-risk of receiving inadequate
end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.
The findings were:
1. Record review of Resident #55's face sheet, dated [DATE], revealed the resident was admitted to the
facility on [DATE] with diagnoses including Protein Calorie Malnutrition, Gastrostomy Status, and Colostomy
Status.
Record review of Resident #55's comprehensive MDS, dated [DATE], revealed a BIMS score of 03 which
indicated severe cognitive impairment.
Record review of Resident #55's care plan, effective [DATE] - Present ([DATE]), revealed, [Resident #55]
requires hospice as evidenced by terminal illness of: . Protein Calorie Malnutrition.
Record review of Resident #55's physician orders as of [DATE], revealed an order dated [DATE], Admit to
[Hospice Company Name], Hospice [diagnosis]: Protein [Calorie] Malnutrition.
Record review of Resident #55's facility clinical record as of [DATE] revealed his hospice Certification of
Terminal Illness form was not included in the record.
During an interview with the Medical Records Director on [DATE] at 3:22 p.m., the Medical Records
Director confirmed Resident #55's hospice Certification of Terminal Illness form was not included in his
facility clinical record and confirmed the form should have been in the record. The Medical Records Director
stated the Social Worker was responsible for ensuring each resident's hospice documentation was
complete and correct.
During an interview with the DON on [DATE] at 9:30 am, the DON stated that the Social Worker was out of
the country and unavailable for interview.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676353
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676353
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coronado at Stone Oak
19638 Stone Oak Parkway
San Antonio, TX 78258
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2. Record review of Resident #53's face sheet, dated [DATE], revealed the resident was admitted to the
facility on [DATE] with diagnoses including Dysphagia following Cerebral Infarction, Heart Failure, and
Cerebral Infarction.
Record review of Resident #53's quarterly MDS, dated [DATE], revealed a BIMS score of 07 which
indicated severe cognitive impairment.
Record review of Resident #53's care plan, effective [DATE] - Present ([DATE]), revealed, [Resident #53]
requires hospice as evidenced by terminal illness of: . Dysphagia following Cerebral Infarction.
Record review of Resident #53's physician orders as of [DATE], revealed an order dated, Admit to [Hospice
Company Name], Hospice [diagnosis]: Dysphagia following Cerebral Infarction.
Record review of Resident #55's facility clinical record as of [DATE] revealed his Hospice Election form was
completed incorrectly, the Certification of Terminal Illness form was missing, and the Hospice Plan of Care
had expired.
Record review of Resident #55's Hospice Election Form, dated [DATE], had the name of the resident's
responsible party in the box intended for the resident's name, and did not have the resident's name printed,
written, or signed anywhere on the form.
Record review of Resident #55's Hospice Plan of Care revealed that it expired [DATE].
During an interview with the Medical Records Director on [DATE] at 3:22 p.m., the Medical Records
Director confirmed that Resident #53's Hospice Election form was completed incorrectly, the Certification of
Terminal Illness form was missing, and the Hospice Plan of Care had expired. The Medical Records
Director stated that the Social Worker was responsible for ensuring that each resident's hospice
documentation was complete and correct.
During an interview with the DON on [DATE] at 9:30 am, the DON stated that the Social Worker was out of
the country and unavailable for interview.
3. Record review of Resident #22's face sheet, dated [DATE], revealed the resident was admitted to the
facility on [DATE] with diagnoses that included: Parkinson's, anemia, bipolar, and major depressive disorder.
Record review of Resident #22's quarterly MDS, dated [DATE], revealed the resident had a BIMS of 8,
which indicated moderate cognitive impairment.
Record review of Resident #22's hospice binder and EHR did not reveal a hospice election form.
During an interview on [DATE] at 3:10 p.m., Mediccal Records stated Resident #22's hospice election form
was not in her EHR. She further stated that this particular hospice company had access to the facility's
EHR and was able to add all the required documentation in the EHR. Medical Records stated she was not
aware of anyone at the facility was responsible for overseeing the hospice records. She was also not aware
of a potential harm to resident's by not having the required documentation.
During an interview on [DATE] at 3:33 p.m., the DON stated it was a team effort that was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676353
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676353
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Coronado at Stone Oak
19638 Stone Oak Parkway
San Antonio, TX 78258
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
responsible for the hospice records. She further stated that no one specifically was responsible for ensuring
the hospice records had all the correct documentation. The DON stated she did not believe there was a
potential harm to residents by not having all the required documentation for the hospice records.
During an interview on [DATE] at 3:10 p.m., the Administrator stated the MDS workers should be
responsible for the hospice records, however, collectively with the help from the SW too. The Administrator
stated he did not believe there was a potential harm to residents by not having all the required
documentation for hospice in their records.
Record Review of Residents #55, #53, and #22's Hospice provider contract, dated [DATE], revealed,
Coordinated Plan of Care: Hospice and [Facility] shall coordinate, establish, and agree upon a coordinated
plan of care for Hospice patients residing in the [Facility] .
Record Review of the facility policy, Hospice Program, revised [DATE], revealed, Our facility has designated
[blank] (Name) [blank] (Title) to coordinate care provided to the resident by our facility and the hospice staff
. He or she is responsible for the following: . Obtaining the following information from the hospice: (1) The
most recent plan of care specific to each [hospice] resident, (2) Hospice election form, (3) Physician
certification and recertification of terminal illness .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676353
If continuation sheet
Page 7 of 7
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F849 - Hospice services
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.
FAQ · About this visit
Common questions about this visit
What happened during the February 17, 2023 survey of CORONADO AT STONE OAK?
This was a inspection survey of CORONADO AT STONE OAK on February 17, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CORONADO AT STONE OAK on February 17, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.