Windsor Mission Oaks, San Antonio, TX

The Essentials

Summary

Across 5 inspections from March 2023 to June 2026, state surveyors documented 37 findings at Windsor Mission Oaks; 37 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections: 5; 2023–2026, complaint and standard
Findings: 37; Deficiencies cited by state inspectors
Corrected: 37; Of 37 findings, with a recorded correction date
Penalties: 1; 1 fine; payment not published

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2023	1	11	0
2024	2	15	1
2025	1	10	0
2026	1	1	0

What the Record Shows

37 of 37 findings have a recorded correction date.
CMS lists 1 enforcement action in the window: 1 fine of $10,842, its payment not published.
3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, June 27, 2025, recorded 10 findings (most serious: Level F).

What to Ask About

Continence and Catheter Care, Cited in Three Inspections
Kitchen and Food Safety, Cited in Three Inspections
Infection Control, Cited in Three Inspections
Citation F925, Cited in Three Inspections
Citation F583, Cited in Two Inspections
Accident Hazards and Supervision, Cited in Two Inspections
Citation F726, Cited in Two Inspections
Medication Labeling and Storage, Cited in Two Inspections
Citation F921, Cited in Two Inspections

Report at a Glance

Facility: Windsor Mission Oaks
Address: 3030 S Roosevelt Ave, San Antonio, TX 78214
CMS Certification Number: 675409
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 150
Ownership: Non profit - Other
Record Window: March 31, 2023 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Jun 122026
Complaint investigation
1 finding
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 13, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jun 272025
Standard health inspection
10 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jun 28, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Jun 28, 2025
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Jun 28, 2025
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Jun 28, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 28, 2025
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jun 28, 2025
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Jun 28, 2025
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jun 28, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 28, 2025
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Jun 28, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 232024
Complaint investigation
2 findings
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 24, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 24, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 82024
Standard health inspection
13 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 4, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 9, 2024
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected May 9, 2024
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected May 9, 2024
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected May 9, 2024
- F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Level ENo actual harm, potential for moreCorrected May 9, 2024
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level ENo actual harm, potential for moreCorrected May 9, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected May 9, 2024
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected May 9, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 9, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected May 9, 2024
- F758Implement 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.Level DNo actual harm, potential for moreCorrected May 9, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 9, 2024
Enforcement Action
Civil money penalty, $10,842 imposed May 8, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 8, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Mar 312023
Standard health inspection
11 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Apr 1, 2023
- F578Honor 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.Level ENo actual harm, potential for moreCorrected Apr 1, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Apr 1, 2023
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Apr 1, 2023
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Apr 1, 2023
- F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level DNo actual harm, potential for moreCorrected Apr 1, 2023
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 1, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 1, 2023
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Apr 1, 2023
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Apr 1, 2023
- F814Dispose of garbage and refuse properly.Level CPotential for minimal harmCorrected Apr 1, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Continence and Catheter Care, Cited in Three Inspections
Inspectors cited F690 in March 2023, May 2024 and June 2025. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F690 across all 5 inspections, oldest to newest
2
Kitchen and Food Safety, Cited in Three Inspections
Inspectors cited F812 in March 2023, May 2024 and June 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F812 across all 5 inspections, oldest to newest
3
Infection Control, Cited in Three Inspections
Inspectors cited F880 in May 2024, June 2025 and June 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F880 across all 5 inspections, oldest to newest
4
Citation F925, Cited in Three Inspections
Inspectors cited F925 in March 2023, May 2024 and June 2025. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F925 across all 5 inspections, oldest to newest
5
Citation F583, Cited in Two Inspections
Inspectors cited F583 in March 2023 and May 2024. The agency describes it this way: Keep residents' personal and medical records private and confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F583 across all 5 inspections, oldest to newest
6
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in March 2023 and May 2024. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F689 across all 5 inspections, oldest to newest
7
Citation F726, Cited in Two Inspections
Inspectors cited F726 in May 2024 and June 2025. The agency describes it this way: 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. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F726 across all 5 inspections, oldest to newest
8
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in May 2024 and June 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F761 across all 5 inspections, oldest to newest
9
Citation F921, Cited in Two Inspections
Inspectors cited F921 in May 2024 and June 2025. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242526F921 across all 5 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in three inspections, most seriously at level E.
02
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
03
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
04
What changed after F925 was cited, and how do you check it now?
Citation F925: cited in three inspections, most seriously at level E.
05
What changed after F583 was cited, and how do you check it now?
Citation F583: cited in two inspections, most seriously at level D.
06
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level J.
07
What changed after F726 was cited, and how do you check it now?
Citation F726: cited in two inspections, most seriously at level E.
08
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level E.
09
What changed after F921 was cited, and how do you check it now?
Citation F921: cited in two inspections, most seriously at level E.
10
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
11
What led to the 2024 fine, and has it been paid?
A $10,842 civil money penalty was imposed May 8, 2024. CMS publishes the fine, not whether it has been paid.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Mar 31, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection May 8, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection May 23, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jun 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jun 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 675409
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowMarch 31, 2023 – October 1, 2026

CMS publishes about three inspection cycles; inspections before March 2023 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.