Cycle 1
Health 2025-06-27 · Fire 2025-06-27
10 health deficiencies
Top issue: Environmental (2 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
San Antonio, TX
Windsor Mission Oaks
2-star overall rating with 3-star inspections with $10,842 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3030 S Roosevelt Ave, San Antonio, TX
(210) 924-8151
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
128
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
1994-10-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.58
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.68
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.19
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
24%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,843
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.42
Composite VBP score used to determine payment impact.
Payment multiplier
1.0010
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.35
Baseline 34.07% · Performance 29.54% · Measure score 8.35 · Achievement 8.35 · Improvement 4.41
Adjusted total nurse staffing
1.13
Baseline 3.02 hours · Performance 3.4 hours · Measure score 1.13 · Achievement 1.13 · Improvement 0.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 141 |
| Staff flu vaccination coverage | 85.4% |
42%
43.4 pts better
|
Numerator 117 · Denominator 137 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
97.9%
1.3 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.3%
0.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.9% · Q3 3.3% · Q4 1.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
2.7%
0.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 2.9% · Q4 2.5% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
3.3%
0.7 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 1.8% · Q4 3.6% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.2% |
18.9%
22.3 pts worse
|
19.6%
21.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 40.2% · Q3 40.4% · Q4 40.5% · 4Q avg 41.2% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.3% |
15.4%
7.1 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.7% · Q3 7.7% · Q4 8.7% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
16.1%
5.4 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 14.0% · Q3 12.5% · Q4 8.2% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 1.6% · Q4 0.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
15.0%
6.3 pts worse
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 25.5% · Q3 20.0% · Q4 18.2% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.2%
3.3 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.1% · Q4 1.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.7% |
89.7%
18 pts worse
|
81.7%
10 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 71.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-03-31 · Fire 2023-03-31
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-28
E · Potential for more than minimal harm
2025-06-27
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-06-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-28
C · Minimal harm
2025-06-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
F · Potential for more than minimal harm
2024-05-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-05-08
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-05-09
C · Minimal harm
2024-05-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-08
E · Potential for more than minimal harm
2023-03-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-01
C · Minimal harm
2023-03-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-28
E · Potential for more than minimal harm
2025-06-27
F690 · Quality of Life and Care Deficiencies
Health
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 2025-06-28
E · Potential for more than minimal harm
2025-06-27
F726 · Nursing and Physician Services Deficiencies
Health
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 2025-06-28
E · Potential for more than minimal harm
2025-06-27
F761 · Pharmacy Service Deficiencies
Health
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 2025-06-28
E · Potential for more than minimal harm
2025-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-28
E · Potential for more than minimal harm
2025-06-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-06-28
E · Potential for more than minimal harm
2025-06-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-06-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-06-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-06-27
F693 · Quality of Life and Care Deficiencies
Health
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 2025-06-28
D · Potential for more than minimal harm
2024-05-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-24
J · Immediate jeopardy
2024-05-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-04
F · Potential for more than minimal harm
2024-05-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F761 · Pharmacy Service Deficiencies
Health
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 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-05-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-05-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-05-08
F690 · Quality of Life and Care Deficiencies
Health
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 2024-05-09
D · Potential for more than minimal harm
2024-05-08
F726 · Nursing and Physician Services Deficiencies
Health
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 2024-05-09
D · Potential for more than minimal harm
2024-05-08
F758 · Pharmacy Service Deficiencies
Health
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 2024-05-09
D · Potential for more than minimal harm
2024-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-09
E · Potential for more than minimal harm
2023-07-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-03-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-01
E · Potential for more than minimal harm
2023-03-31
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-04-01
E · Potential for more than minimal harm
2023-03-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-01
E · Potential for more than minimal harm
2023-03-31
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-31
F690 · Quality of Life and Care Deficiencies
Health
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 2023-04-01
D · Potential for more than minimal harm
2023-03-31
F849 · Administration Deficiencies
Health
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.
Corrected 2023-04-01
C · Minimal harm
2023-03-31
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-04-01
Penalties and ownership
What sits behind the stars
$10,842
2024-05-08
Fine
Fine · fine $10,842
Fine
Ownership
Val Verde County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Jurado, Jorge
Corporate Officer · Individual
Ramirez, Hermelindo
Operational/Managerial Control · Individual
Regency Ihs Of Windsor Mission Oaks, LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Val Verde County Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
The Rio At Mission Trails
San Antonio, TX
3-star overall rating with 3-star inspections with $153,825 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
San Jose Nursing Center
San Antonio, TX
2-star overall rating with 3-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Highland Nursing Center
San Antonio, TX
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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