18514 Sonterra Place, San Antonio, TX 78258 · Bexar County · (210) 545-4800
124 certified beds, about 102 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2007
CMS Care Compare ratings, data as of September 1, 2026 · CCN 676158 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 10, 2026, inspectors cited 7 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 46 health citations since December 2023, 5 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists 3 fines totaling $80,964 in the last three years; the largest was $48,718, and the latest is dated April 25, 2025.
Nurses and nurse aides worked 3.53 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.25 of those hours.
54.6% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to The Ensign Group, an affiliated group of 344 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 46 health citations on file.
Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 8 residents (Resident #3, #4, and #14) reviewed for care plans.1. The facility failed to ensure Resident #4's comprehensive care plan was updated to reflect that resident was no longer taking cephalexin. 2. The facility failed to ensure Resident #3's comprehensive care plan was updated with his current ADLs. 3. The facility failed to ensure Resident #14's comprehensive care plan included that she had contractures in her legs. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to ensure the ice scoop was stored outside of the kitchen's ice machine.2. The facility failed to write a correct temperature for the reach-in refrigerator next to the food preparation areas for 07/01/2026 evening temperature.3. The facility failed to throw out cabbage that had black substance on 07/07/2026.4. The facility failed to keep a personal beverage away from storage of disposable plates.5. The facility failed to ensure Dietary Aide F was not wearing a necklace and small hoop earrings while preparing food for 07/08/2026 lunch. These failures could place residents at risk for food borne illness.
Inspectors wroteBased 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 two (2) of two (2) residents (Resident #23 and Resident # 116) reviewed for hospice services. 1. The facility failed to maintain the current hospice plan of care to ensure Resident #23 received adequate end-of-life care. 2. The facility failed to maintain the current hospice plan of care to ensure Resident #116 received adequate end-of-life care. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure at the time each resident is admitted , the facility had physician orders for the resident's immediate care for 1 of 8 residents (Resident #29) reviewed for new admissions. The facility failed to ensure Resident #29 had an order in place to provide catheter care for an indwelling urinary catheter. This failure could lead to residents not receiving necessary care.
Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for two (2) of eight (8) residents (Resident #126 and Resident #64) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #126 was coded on her Discharge Return Anticipated MDS assessment, dated 04/13/2026, for having received tube feeding while a resident and at discharge. 2. The facility failed to ensure Resident #64 was coded on her Quarterly MDS assessment, dated 05/11/2026, for having received a therapeutic diet while a resident. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.
Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 Residents (Resident #133) whose care plan records were reviewed. The facility failed to ensure Resident #133's baseline care plan included the resident's indwelling urinary catheter. This deficient practice could contribute to residents not having their needs met based on their assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #21) reviewed for infection control, in that: The facility failed to ensure signage was posted to alert staff that the resident was on Enhanced Barrier Precautions. The facility failed to ensure there was an active order for the use of Enhanced Barrier Precautions. This failure could place residents at risk of infection due to improper care practices.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 5 Residents (Resident #1) reviewed for medication storage:The facility failed to ensure Resident #1 did not have a medication cup with pills and a medication cup with a medication in powder form at the bedside. These failures could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with State and Federal Laws for 1 of 4 medication carts (300 hall medication cart) reviewed for storage of drugs and biologicals. The facility failed to ensure the medication cart for 300 hall was locked and secured when it was unattended. This failure could place residents at risk of medication misuse or drug diversion.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the right for a resident to refuse or discontinue treatment for 1 of 6 Residents (Resident #155) whose records were reviewed for resident rights. LVN H/Treatment Nurse, failed to stop wound treatment after Resident #155 yelled out in pain multiple times for her to stop on 5/13/25. This deficient practice could affect any resident and could result in residents believing their right to say stop does not matter.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #155) whose records were reviewed for pain management. LVN H/Treatment Nurse, failed to ensure Resident #155 received a PRN pain medication prior to assessment Resident #155 and then failed to stop wound treatment when Resident #155 yelled out in pain multiple times for her to stop on 5/13/25. This deficient practice could affect any resident experiencing pain and undue pain and mental distress.
Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 Residents (Resident #150) who were reviewed for dignity. The facility failed to ensure Resident #150 had clothes to wear while providing physical therapy out in the hallway. This deficient practice could affect any resident and contribute to feelings of dissatisfaction or poor self-esteem.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #8) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #8. This deficient practice could place residents at risk of keeping them from calling for help as needed.
Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Residents #259) reviewed for grievances. On 5/10/2025 Resident #259 made a grievance to the cook to which he did not document and/or report the grievance. This failure could place residents at risk for harm by leaving residents with frustration and demoralization.
Inspectors wroteBased on observations , interviews and record reviews the facility failed to ensure alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or not later than 24 hours if the events that cause the allegation do not involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 8 residents (Resident #259 ) reviewed for reporting alleged verbal abuse. On Monday 5/12/2025 Resident #259 reported to the assistant food service manager (AFSM) that on Saturday 5/10/2025 the cook was rude and yelled while in his room reviewing the lunch meal served. [...]
Inspectors wroteBased on observations , interviews and record reviews the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated, for 1 of 8 residents (Resident #259 reviewed for investigating alleged verbal abuse. On Monday 5/12/2025 Resident #259 reported to the assistant food service manager (AFSM) that on Saturday 5/10/2025 the cook was rude and yelled while in his room reviewing the lunch meal served. The AFSM did not report the alleged verbal abuse and or mistreatment. The facility did not investigate the allegation of verbal abuse. The failure could place residents at risk for verbal abuse.
Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 24 residents (Resident #84) reviewed for MDS transmission. Resident #84's discharge MDS assessment was completed but not transmitted within 14 days of completion. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.
Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 4 Residents (Resident 150 and Resident #155) whose records were reviewed. 1. The facility failed to ensure Resident #150's baseline CP included the use of side rails. 2. The facility failed to ensure Resident #155's baseline CP included the use of side rails. This deficient practice could affect any resident and contribute to residents not having their needs met based on their assessment.
Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframe's to meet a resident's medical and nursing needs for 1 of 6 Residents #Resident #21 whose records were reviewed. The facility failed to include the use of 1/2 side rails on Resident #21's Care Plan since his admission, 3/28/25. This deficient practice could affect any resident and contribute to residents not having their needs met according to their assessment.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for 1 of 7 Residents (Resident #80) whose environment was reviewed for safety hazards. Nursing staff failed to remove 3 razors from Resident #80's bathroom. This deficient practice could affect residents exposed to the razors and could contribute to avoidable accidents.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 6 Residents (Resident #80) whose records were reviewed for CPAP care. Nursing staff failed to store Resident #80's CPAP mask in a plastic bag and failed to clean it per facility policy. This deficient practice could affect residents with respiratory needs and could contribute to upper respiratory infections.
Inspectors wroteBased on observation, interview and record review the facility failed to assess the resident for risk of entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 of 6 Residents (Resident #21 and Resident #153) whose records were reviewed for the use of side rails. 1. Nursing staff failed to obtain physician orders, a consent, and did not make other efforts prior to the implementing the use of SRs for Resident #21. 2. Nursing staff failed to obtain physician orders and a consent for the use of SRs for Resident #153. These deficient practices could affect any resident and could contribute to unavoidable accidents.
Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs without adequate indications for its use for 1 of 6 Resident (Resident #151) whose records were reviewed. Nursing staff failed to obtain a consent from Resident #151's family representative for the use of Hydorxyzine (used for anxiety). This deficient practice could affect any resident who received psychotropic medications and could contribute to the use of unnecessary medications. Review of Resident #151's face sheet, dated 5/15/25, revealed she was admitted to the facility on [DATE] with diagnosis including unspecified Dementia. Review of Resident #151's physician orders for May 2025 revealed an order hydrOXYzine HCl Oral Tablet 25 MG (HydrOXYzine HCl) Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 24 residents (Resident #150) reviewed for medications storage. During medications administration, LVN A left medications at bedside of Resident #150. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of medications.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 5 residents (Resident #23 and #150) reviewed for infection control, in that: 1. While administering medications for Resident #23, MA B did not sanitize the mobile blood pressure machine. 2. While Administering medications for Resident #150, LVN A did not sanitize of wash her hands between change of gloves. LVN A did not change her gloves prior to start care on Resident #150 These deficient practices could place residents at-risk for infection due to improper care practices.
Inspectors wroteBased on interviews and record reviews, the facility failed to prepare a comprehensive care plan that included to the extent practicable, the participation of the resident and the resident's representative(s) and failed to review and revise resident care plans after each assessment, for 2 of 4 residents (Resident #1 and #2) reviewed for care plan revision/timing. The facility failed to ensure Resident #1 had quarterly care plan reviews in February 2024 and May 2024 (2 out of 5), and Resident #2 had quarterly care plan reviews in March 2024, June 2024 and January 2025 (3 out of 6). This failure could affect residents care/services and may cause a delay in treatment and/or decline in health.
Inspectors wroteBased on interview and record review the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1 had documented weekly skin evaluations per the facility policy on 6 out of 7 occasions (08/24/24, 08/31/24, 09/07/24, 09/14/24, 09/21/24, 09/28/24) from 08/21/24 to 10/05/24. This failure could place residents at risk for improper care due to inaccurate records.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #1) reviewed for significant medication errors, in that: The facility failed to ensure that Resident #1 was administered Touch U-200 (long-acting insulin) and Novo Log (rapid-acting insulin) for 2 days from 3/12/25 to 3/14/25. The resident was sent to the hospital, admitted and diagnosed with Diabetic [NAME] Acidosis. The non-compliance was identified as IJ past non-compliance. The noncompliance began on 3/12/2025 and ended on 3/17/25. The facility had corrected the non-compliance before the survey began. This failure placed resident at risk for adverse side effects, and life-threatening complications .
Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Neglect, in that: The facility did not report an allegation of neglect per facility policy to the State Survey Agency (HHSC) when a medication error for Resident # 1 occurred. This deficient practice could affect any resident and could contribute to further neglect.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (400 hall medication cart) reviewed for drug security. The 400 Hall nurse's medication cart was left unattended with a blister package of medication Tamulosin HCL for Resident #4 on top of the cart. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects.
Inspectors wroteBased on observations, interviews, and record review the facility failed to implement a comprehensive person-centered care plan for 2 of 8 residents (Resident #1 and Resident #2) reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was receiving assistance with eating as detailed in his Care Plan and was left unsupervised in his room during the evening meal on 8/6/24. Resident #1 was pronounced deceased at the facility on 8/6/24. 2. The facility failed to ensure Resident #2 was receiving assistance with eating as detailed in her Care Plan. On 8/11/24 at 12:13 pm an Immediate Jeopardy (IJ) was identified. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents (Residents #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was not left unsupervised in his room during the evening meal on 8/6/24. Resident #1 was pronounced deceased at the facility on 8/6/24. On 8/9/24 at 4:21 pm an Immediate Jeopardy (IJ) was identified. While the immediacy was removed on 8/12/24 at 7:42 pm, the facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed all residents at risk for serious injury, harm, and/or death due to lack of appropriate supervision.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to post the following information on a daily basis: Facility name, the current date, the total number, and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, Licensed practical nurses, Certified nurse aides, and Resident census. For 1 of 1 daily nursing staff posting. The facility failed to coordinate the generation and posting of the nursing daily staffing report. This deficient practice could deny residents and visitors nurse staffing information readily available in a readable format at any given time.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 3 (100 Hall medication aide cart, nurse medication cart, and treatment cart) of 8 medication and treatment carts reviewed for drugs and biologicals were stored in locked compartments. The 100-hall medication aide cart, the nurse medication cart, and the treatment cart were unlocked and unsupervised. This failure could place residents at risk for harm by unsecured and uncontrolled medications.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 10 snacks reviewed for preparation, distribution, and storage. The facility prepared and distributed sandwiches without labeling the sandwiches with the dates they were prepared and the dates the foods should not be served and thrown out. This deficient practice could place residents at risk for food borne illnesses.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 5 (Residents #6, #17, #19, #53 and #67) out of 24 residents reviewed for MDS assessments. 1. Facility failed to ensure Resident #6's quarterly MDS assessment with an ARD of 03/23/2024 reflected resident receiving hospice services. 2. Facility failed to ensure Resident #17's significant change MDS assessment with an ARD of 03/12/2024 reflected resident receiving hospice services. 3. [...]
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 residents (Residents #19, #53 and 127) of 24 residents reviewed for care plans. 1. Facility failed to implement Resident #19's care plan which reflected she required a floor mat beside her bed as a fall prevention. 2. Facility failed to ensure Resident #53's bowel and bladder incontinence was reflected in his comprehensive care plan with a revised date of 12/11/2023. 3. Facility failed to ensure Resident #127's hospice services were reflected in his comprehensive care plan with a revised date of 02/18/2024. [...]
Inspectors wroteBased on interview, and record review, the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility, reviewed for registered nurse coverage. RN 8-hour coverage was not available for 7 days in the period 11/04/23 to 12/15/23. This deficient practice had the potential to affect all residents in the facility by leaving staff without supervisory coverage of an RN.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. The facility failed to ensure [NAME] I prepared the pureed pasta salad in a sanitary fashion. The facility failed to ensure insulated plate lids and insulated plate bases were air dried prior to stacking them with water droplets and meal prep. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for one (Resident #56) out of 24 residents reviewed for comprehensive care plans. Resident #56's comprehensive care was not revised to reflect he was on an LCS/NAS regular texture diet. This deficient practice could affect residents placing them at risk for not receiving necessary care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Residents #53) reviewed for incontinent care.: While providing incontinent care for Resident #53, CNA C did not return Resident #53's foreskin to the original position. This deficient practice could place residents at-risk for infection, paraphimosis (urologic emergency in uncircumcised males) and skin break down due to improper care practices.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure personal privacy during personal care for 1 of 5 resident (Resident #1) observed for personal privacy in that: While performing the incontinent care for Resident #1, CNA A and CNA B did not ensure Resident #1's personal privacy. This deficient practice could affect residents and could result in loss of dignity and low self-esteem.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 4 residents (Resident #2) reviewed for storage of drugs. LVN C left Resident #2's morning medications at bedside. This deficient practice could place residents at risk of medication misuse and diversion.
Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #3) reviewed for accuracy of medical records in that: CNA D documented she gave Resident #3's clonazepam (a medication for seizures) on 2/20/24, which was after Resident #3 ran out of clonazepam on 2/19/24 and before the medication was restocked on 2/22/24. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 4 Residents (Resident #1 and #2), reviewed for care plan development. 1. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for a diagnoses GERD (gastro-esophageal reflux disease, also known as acid reflux), eosinophilic esophagitis (inflammation of the esophagus) and history of GI (gastro-intestinal) bleeding. 2. [...]
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Residents #2) reviewed for medication administration. The facility failed to ensure Resident #2 was administered midodrine (a medication used to increase blood pressure) by LVN C who had dispensed the medication. This failure could place residents at risk for a delay in medication administration and medication error and could result in a decline in health.
7 fire safety citations on file: 5 on July 10, 2026, 1 on May 15, 2025, 1 on April 19, 2024.
| Date | Penalty | Amount or 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 from September 13, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.53 | 3.39 | 3.86 |
| Registered nurses | 0.25 | 0.43 | 0.69 |
| All nursing staff on weekends | 2.86 | 2.98 | 3.42 |
| Nurse aides | 1.94 | ||
| Licensed practical nurses | 1.34 | ||
| Nursing staff turnover (share who left in a year) | 54.6% | 55.3% | 45.8% |
| Registered nurse turnover | 66.7% | 54.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.77 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.80 on weekdays and 2.86 on weekends, 25% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.74 in April to June 2025 to 3.53 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.53 | 0.25 | 3.80 | 2.86 | 0.0% | 0 of 90 | 102 |
| Oct to Dec 2025 | 3.66 | 0.39 | 3.91 | 3.04 | 0.0% | 0 of 92 | 99 |
| Jul to Sep 2025 | 3.72 | 0.33 | 3.96 | 3.11 | 0.8% | 0 of 92 | 100 |
| Apr to Jun 2025 | 3.74 | 0.31 | 4.03 | 3.01 | 0.7% | 0 of 91 | 98 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.6 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.6 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.3 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.5 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.9 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.2 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 26.2 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.6 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.9 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Sonterra Health Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (52.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
52.9% this home
No different from the national rate
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 160 eligible stays.
10.3% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 191 eligible stays.
6.8% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 77 eligible stays.
85.3% this home
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 61 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 79 residents counted.
1.4% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 79 residents counted.
97.8% this home
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 45 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: DEWITT MEDICAL DISTRICT. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ashton, Andrew | Managing control - governing body | Individual | 04/01/2017 | |
| Mansoor, Saad | Managing control - governing body | Individual | 04/29/2019 | |
| Alexander, Alma | Corporate officer | Individual | 05/27/2020 | |
| Burnam, Soon | Corporate officer | Individual | 04/01/2017 | |
| Keetch, Chad | Corporate officer | Individual | 03/01/2011 | |
| Brackenridge Healthcare Inc | Operational/managerial control | Organization | 04/01/2017 | |
| Ashton, Andrew | Operational/managerial control | Individual | 04/01/2017 | |
| Mansoor, Saad | Operational/managerial control | Individual | 04/29/2019 | |
| Brackenridge Healthcare Inc | Adp of the SNF | Organization | 10/24/2025 | |
| Ensign Services Inc | Adp of the SNF | Organization | 05/01/2016 | |
| National Health Investors, Inc. | Adp of the SNF | Organization | 04/01/2017 | |
| Texas Nhi Investors, LLC | Adp of the SNF | Organization | 04/01/2017 | |
| Ashton, Andrew | Adp of the SNF | Individual | 04/01/2017 | |
| Mansoor, Saad | Adp of the SNF | Individual | 04/29/2019 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.