Windsor Mission Oaks
3030 S Roosevelt Ave · San Antonio, TX · 78214 · 2109248151
150 certified beds Non profit - Other Chain: Wellsential Health
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
RN staffing in the bottom 10% nationally
0.29 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Total nurse staffing below 3.0 hours per resident-day
2.70 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 2 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 2.70 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.29 | 0.55–0.75 |
| Weekend hours / resident-day | 2.14 | ≈ weekday level |
| Nursing turnover / year | 24% | median 45% |
| Fines (3-yr window) | 1 · $10,842 |
Inspection citations (37 in the current record)
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Potential for harm · D June 27, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected June 28, 2025 · Resident Rights
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Potential for harm · D June 27, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected June 28, 2025 · Resident Assessment and Care Planning
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Potential for harm · E June 27, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected June 28, 2025 · Quality of Life and Care
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Potential for harm · D June 27, 2025
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.
Corrected June 28, 2025 · Quality of Life and Care
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Potential for harm · E June 27, 2025
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.
Corrected June 28, 2025 · Nursing and Physician Services
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Potential for harm · E June 27, 2025
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.
Corrected June 28, 2025 · Pharmacy Service
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Potential for harm · F June 27, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected June 28, 2025 · Nutrition and Dietary
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Potential for harm · E June 27, 2025
Provide and implement an infection prevention and control program.
Corrected June 28, 2025 · Infection Control
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Potential for harm · E June 27, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected June 28, 2025 · Environmental
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Potential for harm · E June 27, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected June 28, 2025 · Environmental
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Potential for harm · D May 23, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 24, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 23, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected May 24, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J May 8, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 4, 2024 · Quality of Life and Care
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Potential for harm · D May 8, 2024 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected May 9, 2024 · Resident Rights
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Potential for harm · D May 8, 2024 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected May 9, 2024 · Resident Rights
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Potential for harm · D May 8, 2024 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected May 9, 2024 · Quality of Life and Care
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Potential for harm · D May 8, 2024 · found via complaint
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.
Corrected May 9, 2024 · Nursing and Physician Services
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Potential for harm · D May 8, 2024 · found via complaint
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.
Corrected May 9, 2024 · Pharmacy Service
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Potential for harm · E May 8, 2024 · found via complaint
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.
Corrected May 9, 2024 · Pharmacy Service
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Potential for harm · F May 8, 2024 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 9, 2024 · Nutrition and Dietary
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Potential for harm · D May 8, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected May 9, 2024 · Infection Control
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Potential for harm · E May 8, 2024 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected May 9, 2024 · Environmental
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Potential for harm · E May 8, 2024 · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected May 9, 2024 · Environmental
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Potential for harm · E May 8, 2024 · found via complaint
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected May 9, 2024 · Resident Rights
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Potential for harm · E May 8, 2024 · found via complaint
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected May 9, 2024 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| May 8, 2024 | Fine | $10,842 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 675409 · certified since October 20, 1994. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.