Windsor Mission Oaks

Name: Windsor Mission Oaks
Address: 3030 S ROOSEVELT AVE, San Antonio, TX, 78214, US
Telephone: 2109248151

3030 S Roosevelt Ave, San Antonio, TX 78214 · Bexar County · 150 certified beds · avg 123 residents/day · certified since Oct 20, 1994

Part of chain: WELLSENTIAL HEALTH (67 facilities, chain avg rating 2.7★)

3/5

Health inspection rating (on-site)

Serious findings on record

$10,842

Fines, last 3 years

2.82

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · May 8, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: May 4, 2024 (Past Non-Compliance)

All citations in the current public record (37)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 12, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jun 27, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 27, 2025	E · Potential for harm, repeated	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jun 27, 2025	E · Potential for harm, repeated	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jun 27, 2025	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jun 27, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 27, 2025	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Jun 27, 2025	E · Potential for harm, repeated	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Jun 27, 2025	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jun 27, 2025	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jun 27, 2025	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
May 23, 2024	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
May 23, 2024	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
May 8, 2024	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 8, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
May 8, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
May 8, 2024	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
May 8, 2024	E · Potential for harm, repeated	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
May 8, 2024	E · Potential for harm, repeated	The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. · from a complaint
May 8, 2024	E · Potential for harm, repeated	The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint
May 8, 2024	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
May 8, 2024	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential. · from a complaint
May 8, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
May 8, 2024	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
May 8, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint
May 8, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Mar 31, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 31, 2023	E · Potential for harm, repeated	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Mar 31, 2023	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 31, 2023	E · Potential for harm, repeated	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Mar 31, 2023	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Mar 31, 2023	D · Potential for harm, one-off	The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Mar 31, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 31, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 31, 2023	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Mar 31, 2023	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Mar 31, 2023	C · Minimal risk, facility-wide	The facility did not dispose of garbage and refuse properly.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (13 → 10).

Year	Citations	Serious (G–L)	Worst severity that year
2023	11	0	F
2024	15	1	J ▲
2025	10	0	F
2026	1	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $10,842.

Date	Type	Amount / length
May 8, 2024	Fine	$10,842

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.82	3.46	3.95	bottom 13% in Texas; bottom 9% in the U.S.
Registered Nurse hours	0.30	0.44	0.69	bottom 27% in Texas; bottom 9% in the U.S.
Weekend total nurse staffing	2.28	3.04	3.50	bottom 6% in Texas; bottom 5% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.15	0.34	0.48	bottom 9% in Texas; bottom 5% in the U.S.
Total nursing staff turnover (%)	23.2	55.3	45.8	top 1% in Texas; top 5% in the U.S.
RN turnover (%)	0.0	54.6	42.9	top 1% in Texas; top 1% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.74, RN 0.29, weekend 2.22. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5

Who owns this facility

Non profit - Other

Owner / manager	Type	Role	Stake	Since
CSV Rhea Management Holdco, LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
DWD TX Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Jack and Nancy Dwyer Workforce Development Center INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Reg HG Opco 1, LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Reg HG Opco LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Reg Operator Holdco LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Regency Ihs of Windsor Mission Oaks, LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	04/01/2022
Regency Integrated Health Services LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Regency Texas Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Val Verde County Hospital District	Organization	5% or Greater Direct Ownership Interest	100%	04/01/2022
300 S Roosevelt Avenue LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/01/2022
Baird, Daniel	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/13/2021
Clapp, Barbara	Individual	Managing Control - Governing Body	NOT APPLICABLE	06/01/2021
Cortese, Daren	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/10/2021
Dekowski, Donovan	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Dekowski, Donovan	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2022
Diaz, Christoper	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2025
Diaz, Cris	Individual	Managing Control - Governing Body	NOT APPLICABLE	11/18/2020
Gibson, Patricia	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/01/2021
Givens, Laura	Individual	ADP of the SNF	NOT APPLICABLE	07/01/2015

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
"How is pest control handled here, and when was the last treatment or inspection?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
The Rio at Mission Trails	1.4 mi	San Antonio, TX	★☆☆☆☆	2/5
San Jose Nursing Center	2.0 mi	San Antonio, TX	★★★☆☆	3/5
Highland Nursing Center	2.7 mi	San Antonio, TX	★☆☆☆☆	2/5
Pecan Valley Rehabilitation and Healthcare	3.6 mi	San Antonio, TX	★★★★☆	4/5
Buena Vida Nursing and Rehab-San Antonio	3.7 mi	San Antonio, TX	★☆☆☆☆	1/5	abuseSFF
Legend Oaks Healthcare and Rehabilitation Center -	3.8 mi	San Antonio, TX	★★★☆☆	3/5
Avir at San Antonio	4.1 mi	San Antonio, TX	★☆☆☆☆	2/5
River City Care Center	4.2 mi	San Antonio, TX	★☆☆☆☆	2/5	abuse
Southeast Nursing & Rehabilitation Center	4.2 mi	San Antonio, TX	★★☆☆☆	1/5
San Antonio West Nursing and Rehabilitation	4.9 mi	San Antonio, TX	★☆☆☆☆	1/5
Hunters Pond Rehabilitation and Healthcare	5.0 mi	San Antonio, TX	★★★☆☆	2/5
Memorial Medical Nursing and Rehabilitation	5.1 mi	San Antonio, TX	★☆☆☆☆	1/5

Compare this facility with the 3 closest →

All facilities in San Antonio →

Facility data as of CMS processing date 2026-08-01. CCN 675409.

The Care File

Visit checklist — Windsor Mission Oaks

3030 S Roosevelt Ave, San Antonio, TX 78214 · 2109248151

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $10,842

Most serious findings on record:

▲ May 8, 2024 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
☐ "How is pest control handled here, and when was the last treatment or inspection?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 675409 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)