Non profit - Other · 150 certified beds · CMS number 675409
Windsor Mission Oaks, San Antonio, TX
CMS records 37 health deficiencies at Windsor Mission Oaks in San Antonio, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Jun 27, 2025. The highest severity cited is J (immediate jeopardy to resident health or safety). 1 citation was at the immediate jeopardy level, 1 of them recorded as past non-compliance (fixed before the inspection). CMS lists 1 fine totaling $10,842 in the last three years.
- 37deficiencies, 3 cycles (TX median 25)
- 11in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $10,842fines, last 3 years
- 3CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Windsor Mission Oaks as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Windsor Mission Oaks may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (11 deficiencies)
Standard inspection Jun 27, 2025. CMS counts 11 health deficiencies and 4 fire safety deficiencies in this cycle.
Jun 12, 2026 · Complaint inspection
1 deficiency, highest D
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 13, 2026
Jun 27, 2025 · Standard inspection
10 deficiencies, highest F
F925 · Pest control
Requirement cited (CMS): Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 28, 2025
F921 · Safe, functional, sanitary building
Requirement cited (CMS): Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 28, 2025
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 28, 2025
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Jun 28, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 28, 2025
F726 · Competent nurses and nurse aides
Requirement cited (CMS): Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 28, 2025
F693 · Feeding tube use and care
Requirement cited (CMS): Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 28, 2025
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 28, 2025
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 28, 2025
F552 · Being informed about health and treatment
Requirement cited (CMS): Ensure that residents are fully informed and understand their health status, care and treatments.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 28, 2025
Previous cycle: 13 deficiencies (standard inspection May 8, 2024)
Standard inspection May 8, 2024. CMS counts 13 health deficiencies and 6 fire safety deficiencies in this cycle.
May 8, 2024 · Standard + complaint inspection
13 deficiencies, highest J
F943 · Abuse prevention and dementia training
Requirement cited (CMS): Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 9, 2024
F942 · Resident rights training for staff
Requirement cited (CMS): Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 9, 2024
F925 · Pest control
Requirement cited (CMS): Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 9, 2024
F921 · Safe, functional, sanitary building
Requirement cited (CMS): Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 9, 2024
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 9, 2024
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date May 9, 2024
F761 · Drug labeling and secure storage
Requirement cited (CMS): Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 9, 2024
F758 · Psychotropic drug safeguards
Requirement cited (CMS): Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 9, 2024
F726 · Competent nurses and nurse aides
Requirement cited (CMS): Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 9, 2024
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 9, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), May 4, 2024
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 9, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 9, 2024
Earlier cycle: 13 deficiencies (standard inspection Mar 31, 2023)
Standard inspection Mar 31, 2023. CMS counts 13 health deficiencies and 5 fire safety deficiencies in this cycle.
May 23, 2024 · Complaint inspection
2 deficiencies, highest D
F610 · Investigating and responding to allegations
Requirement cited (CMS): Respond appropriately to all alleged violations.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 24, 2024
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 24, 2024
Mar 31, 2023 · Standard inspection
11 deficiencies, highest F
F925 · Pest control
Requirement cited (CMS): Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 1, 2023
F849 · Hospice services
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 1, 2023
F814 · Garbage disposal
Requirement cited (CMS): Dispose of garbage and refuse properly.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- Correction date Apr 1, 2023
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Apr 1, 2023
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 1, 2023
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 1, 2023
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 1, 2023
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 1, 2023
F640 · Submitting assessment data on time
Requirement cited (CMS): Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 1, 2023
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 1, 2023
F578 · Refusing treatment and advance directives
Requirement cited (CMS): Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 1, 2023
Tags cited in more than one inspection
9 tags cited on more than one inspection date at Windsor Mission Oaks; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F690 Bladder, bowel, and catheter care | 3 | Jun 27, 2025; May 8, 2024; Mar 31, 2023 |
| F812 Food safety and sanitation | 3 | Jun 27, 2025; May 8, 2024; Mar 31, 2023 |
| F880 Infection prevention and control program | 3 | Jun 12, 2026; Jun 27, 2025; May 8, 2024 |
| F925 Pest control | 3 | Jun 27, 2025; May 8, 2024; Mar 31, 2023 |
| F583 Personal privacy and confidential records | 2 | May 8, 2024; Mar 31, 2023 |
| F689 Accident prevention and supervision | 2 | May 8, 2024 (PNC); Mar 31, 2023 |
| F726 Competent nurses and nurse aides | 2 | Jun 27, 2025; May 8, 2024 |
| F761 Drug labeling and secure storage | 2 | Jun 27, 2025; May 8, 2024 |
| F921 Safe, functional, sanitary building | 2 | Jun 27, 2025; May 8, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| May 8, 2024 | Fine | $10,842 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 2.74 h (below the Texas median of 3.27 h)
- RN hours per resident per day
- 0.29 h (below the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.22 h
- Nursing staff turnover
- 23.2% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 3 of 5
- Health inspection rating
- 3 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- Not rated
CMS figures for Windsor Mission Oaks, copied as published; Texas medians are ours.
Facility details
- Address
- 3030 S Roosevelt Ave, San Antonio, TX 78214
- Phone
- (210) 924-8151
- County
- Bexar
- Accepts
- Medicare and Medicaid
- Ownership
- Non profit - Other
- Chain (CMS)
- Wellsential Health
- Certified beds
- 150
- Average residents per day
- 123.1
- In Medicare/Medicaid since
- Oct 20, 1994
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How does the home support residents who need help with toileting or incontinence? (F690, cited 3 times)
- When was the kitchen last inspected, and how are food temperatures checked? (F812, cited 3 times)
- How do staff track and report infections among residents? (F880, cited 3 times)
- How often does a pest control service treat the building? (F925, cited 3 times)
Other nursing homes in San Antonio and the same chain
- San Antonio West Nursing and Rehabilitation
San Antonio · 76 deficiencies - Parklane West Healthcare Center
San Antonio · 68 deficiencies - Castle Hills Rehabilitation and Care Center
San Antonio · 67 deficiencies - Crestway Nursing & Rehabilitation
San Antonio · 65 deficiencies - Oak Park Nursing and Rehabilitation Center
San Antonio · 60 deficiencies - Wurzbach Nursing and Rehabilitation
San Antonio · 58 deficiencies - Longview Hill Nursing and Rehabilitation Center
Longview · 60 deficiencies - Guadalupe Valley Nursing and Rehabilitation Center
Seguin · 52 deficiencies - Town and Country Nursing and Rehabilitation Center
Boerne · 51 deficiencies - Heritage Park Rehabilitation and Skilled Nursing C
Austin · 49 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.