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Inspection visit

Health inspection

WINDSOR MISSION OAKSCMS #6754091 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that residents were free of any significant medication errors for 4 (Resident #2, #3, #4, and #5) of 6 residents reviewed for safe administration of midodrine [a medication intended to raise systolic blood pressure], in that: Residents Affected - Some 1. Resident #2 was administered midodrine on 9 instances outside of the parameters established by the Primary Care Physician (PCP) to hold if greater than 120 systolic blood pressure between 4/01/2023-6/30/2023; 2. Resident #3 was administered midodrine on 45 instances outside of the parameters established by the PCP to hold if greater than 100 systolic blood pressure between 4/01/2023-6/30/2023; 3. Resident #4 was administered midodrine on 47 instances outside of the parameters established by the PCP to hold if greater than 120 systolic blood pressure between 4/01/2023-6/30/2023; 4. Resident #5 was administered midodrine on 18 instances outside of the parameters established by the PCP to hold if greater than 120 systolic blood pressure between 4/01/2023-6/30/2023; This failure could place residents at risk of not receiving the intended therapeutic benefit of drugs and biologics, worsening or exacerbation of chronic medical conditions, and place residents at risk for serious injuries up to and including strokes. The findings included: 1. Record review of admission Record , dated 7/02/2023, revealed Resident #2 was a [AGE] year-old male admitted on [DATE]. Diagnoses included hypotension [low blood pressure]. Record review of quarterly MDS [Minimum Data Set] assessment, dated 5/25/2023, revealed Resident #2's primary reason for admission was debility, cardiorespiratory conditions. Other active diagnoses included: orthostatic hypotension [form of low blood pressure that happens when you stand up from sitting or lying down]. Record review of Resident #2's Care Plan, revised on 2/15/2023, revealed a problem area of, Hypotension; associated interventions included, give medications as ordered, initiated on 2/01/2023. Record review of Resident #2's Order Summary Report, dated 7/02/2023, revealed active orders for: Midodrine HCL [hydrochloride], oral, tablet 5 MG [milligram], give one tablet by mouth three times a day for hypotension, hold for SBP [systolic blood pressure] > [greater than] 120; start date (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 11 Event ID: 675409 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 2/07/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's Medication Administration Record [MAR] for the months of April, May, and June 2023 revealed: Residents Affected - Some *Midodrine was administered out of parameters on 4/21/2023 at 7:00 PM when the systolic blood pressure was 124 administered by LVN A. *Midodrine was administered out of parameters on 4/27/2023 at 7:00 PM when the systolic blood pressure was 122 administered by [unnamed staff]. *Midodrine was administered out of parameters on 5/08/2023 at 7:00 PM when the systolic blood pressure was 134 administered by LVN A. *Midodrine was administered out of parameters on 5/21/2023 at 7:00 PM when the systolic blood pressure was 134 administered by [unnamed staff]. *Midodrine was administered out of parameters on 5/22/2023 at 7:00 AM when the systolic blood pressure was 136 administered by LVN F. *Midodrine was administered out of parameters on 5/22/2023 at 1:00 PM when the systolic blood pressure was 124 administered by LVN F. *Midodrine was administered out of parameters on 5/22/2023 at 7:00 PM when the systolic blood pressure was 122 administered by LVN A. *Midodrine was administered out of parameters on 6/14/2023 at 1:00 PM when the systolic blood pressure was 126 administered by [unnamed staff]. *Midodrine was administered out of parameters on 6/14/2023 at 7:00 PM when the systolic blood pressure was 122 administered by LVN A. 2. Record review of admission Record , dated 7/02/2023, revealed Resident #3 was a [AGE] year-old female admitted on [DATE]. Diagnoses included hypotension. Record review of annual MDS assessment, dated 6/15/2023, revealed Resident #3's primary reason for admission was medically complex conditions. Other active diagnoses included: orthostatic hypotension. Record review of Resident #3's Care Plan, revised on 6/27/2023, did not include a problem area or associated interventions for hypotension or other cardiovascular issues. Record review of Resident #3's Order Summary Report, dated 7/02/2023, revealed active orders for: Midodrine HCL, oral, tablet 10 MG, give one tablet by mouth three times a day for hypotension, hold for SBP > 100; start date 3/20/2023. Record review of Resident #3's MAR for the months of April, May, and June 2023 revealed: *Midodrine was administered out of parameters on 4/03/2023 at 7:00 PM when the systolic blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 pressure was 132 administered by LVN A. Level of Harm - Minimal harm or potential for actual harm *Midodrine was administered out of parameters on 4/04/2023 at 7:00 AM when the systolic blood pressure was 112 administered by LVN F. Residents Affected - Some *Midodrine was administered out of parameters on 4/04/2023 at 1:00 PM when the systolic blood pressure was 112 administered by LVN F. *Midodrine was administered out of parameters on 4/05/2023 at 7:00 AM when the systolic blood pressure was 110 administered by LVN F. *Midodrine was administered out of parameters on 4/05/2023 at 1:00 PM when the systolic blood pressure was 110 administered by LVN F. *Midodrine was administered out of parameters on 4/07/2023 at 7:00 AM when the systolic blood pressure was 112 administered by LVN D. *Midodrine was administered out of parameters on 4/10/2023 at 7:00 AM when the systolic blood pressure was 120 administered by LVN F. *Midodrine was administered out of parameters on 4/10/2023 at 1:00 PM when the systolic blood pressure was 120 administered by LVN F. *Midodrine was administered out of parameters on 4/12/2023 at 7:00 AM when the systolic blood pressure was 116 administered by LVN F. *Midodrine was administered out of parameters on 4/14/2023 at 7:00 PM when the systolic blood pressure was 110 administered by LVN A. *Midodrine was administered out of parameters on 4/15/2023 at 7:00 AM when the systolic blood pressure was 126 administered by LVN D. *Midodrine was administered out of parameters on 4/16/2023 at 7:00 AM when the systolic blood pressure was 111 administered by LVN F. *Midodrine was administered out of parameters on 4/16/2023 at 1:00 PM when the systolic blood pressure was 111 administered by LVN F. *Midodrine was administered out of parameters on 4/17/2023 at 7:00 AM when the systolic blood pressure was 104 administered by LVN F. *Midodrine was administered out of parameters on 4/17/2023 at 1:00 PM when the systolic blood pressure was 104 administered by LVN F. *Midodrine was administered out of parameters on 4/20/2023 at 7:00 PM when the systolic blood pressure was 114 administered by LVN A. *Midodrine was administered out of parameters on 4/21/2023 at 7:00 PM when the systolic blood pressure was 118 administered by LVN A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 Level of Harm - Minimal harm or potential for actual harm *Midodrine was administered out of parameters on 4/22/2023 at 7:00 AM when the systolic blood pressure was 125 administered by LVN F. *Midodrine was administered out of parameters on 4/22/2023 at 1:00 PM when the systolic blood pressure was 125 administered by LVN F. Residents Affected - Some *Midodrine was administered out of parameters on 4/23/2023 at 7:00 AM when the systolic blood pressure was 114 administered by LVN F. *Midodrine was administered out of parameters on 4/23/2023 at 1:00 PM when the systolic blood pressure was 114 administered by LVN F. *Midodrine was administered out of parameters on 4/24/2023 at 7:00 AM when the systolic blood pressure was 126 administered by LVN D. *Midodrine was administered out of parameters on 4/25/2023 at 1:00 PM when the systolic blood pressure was 106 administered by LVN D. *Midodrine was administered out of parameters on 4/26/2023 at 7:00 PM when the systolic blood pressure was 112 administered by LVN A. *Midodrine was administered out of parameters on 4/28/2023 at 7:00 AM when the systolic blood pressure was 124 administered by LVN F. *Midodrine was administered out of parameters on 5/02/2023 at 7:00 PM when the systolic blood pressure was 124 administered by LVN A. *Midodrine was administered out of parameters on 5/05/2023 at 7:00 AM when the systolic blood pressure was 112 administered by LVN F. *Midodrine was administered out of parameters on 5/08/2023 at 7:00 PM when the systolic blood pressure was 114 administered by LVN A. *Midodrine was administered out of parameters on 5/09/2023 at 7:00 AM when the systolic blood pressure was 103 administered by LVN B. *Midodrine was administered out of parameters on 5/09/2023 at 7:00 PM when the systolic blood pressure was 132 administered by LVN A. *Midodrine was administered out of parameters on 5/13/2023 at 1:00 PM when the systolic blood pressure was 110 administered by LVN D. *Midodrine was administered out of parameters on 5/15/2023 at 7:00 AM when the systolic blood pressure was 117 administered by LVN C. *Midodrine was administered out of parameters on 5/15/2023 at 1:00 PM when the systolic blood pressure was 122 administered by LVN C. *Midodrine was administered out of parameters on 5/15/2023 at 7:00 PM when the systolic blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 pressure was 129 administered by LVN C. Level of Harm - Minimal harm or potential for actual harm *Midodrine was administered out of parameters on 5/21/2023 at 1:00 PM when the systolic blood pressure was 128 administered by LVN D. Residents Affected - Some *Midodrine was administered out of parameters on 5/21/2023 at 7:00 PM when the systolic blood pressure was 102 administered by LVN B. *Midodrine was administered out of parameters on 5/22/2023 at 7:00 PM when the systolic blood pressure was 134 administered by LVN A. *Midodrine was administered out of parameters on 5/23/2023 at 7:00 AM when the systolic blood pressure was 102 administered by LVN F. *Midodrine was administered out of parameters on 5/23/2023 at 1:00 PM when the systolic blood pressure was 101 administered by LVN F. *Midodrine was administered out of parameters on 5/26/2023 at 6:00 AM when the systolic blood pressure was 122 administered by LVN A. *Midodrine was administered out of parameters on 5/27/2023 at 7:00 AM when the systolic blood pressure was 132 administered by LVN D. *Midodrine was administered out of parameters on 5/28/2023 at 1:00 PM when the systolic blood pressure was 111 administered by [unnamed staff]. *Midodrine was administered out of parameters on 5/31/2023 at 1:00 PM when the systolic blood pressure was 101 administered by [unnamed staff]. *Midodrine was administered out of parameters on 6/01/2023 at 7:00 PM when the systolic blood pressure was 112 administered by LVN A. *Midodrine was administered out of parameters on 6/02/2023 at 7:00 PM when the systolic blood pressure was 134 administered by LVN A. 3. Record review of admission Record , dated 7/02/2023, revealed Resident #4 was a [AGE] year-old male, admitted on [DATE]. Diagnosis included atrial fibrillation [disease of the heart, characterized by irregular and often faster heartbeat; frequently associated with low blood pressure]. Record review of annual MDS assessment, dated 4/06/2023, revealed Resident #4's primary reason for admission was progressive neurological conditions. Other active diagnoses included: atrial fibrillation. Record review of Resident #4's Care Plan, revised on 6/27/2023, revealed a problem area of, Hypertension [not included on admission Record or MDS assessment] related to lifestyle choices; Interventions listed are associated with hypertension [high blood pressure], not hypotension. Record review of Resident #4's Order Summary Report, dated 7/02/2023, revealed active orders for: Midodrine HCL oral, tablet 5 MG, give one tablet by mouth every 6 hours for hypotension, hold for SBP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 > 120; start date 3/03/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's MAR for the months of April, May, and June 2023 revealed: Residents Affected - Some *Midodrine was administered out of parameters on 4/01/2023 at 6:00 AM when the systolic blood pressure was 130 administered by LVN C. *Midodrine was administered out of parameters on 4/01/2023 at 12:00 PM when the systolic blood pressure was 126 administered by LVN C. *Midodrine was not administered on 4/01/2023 at 6:00 PM when the systolic blood pressure was 118 held by [unnamed staff]. *Midodrine was administered out of parameters on 4/06/2023 at 12:00 PM when the systolic blood pressure was 124 administered by LVN C. *Midodrine was administered out of parameters on 4/11/2023 at 6:00 AM when the systolic blood pressure was 121 administered by LVN B. *Midodrine was administered out of parameters on 4/11/2023 at 12:00 PM when the systolic blood pressure was 124 administered by LVN B. *Midodrine was administered out of parameters on 4/17/2023 at 12:00 PM when the systolic blood pressure was 124 administered by LVN C. *Midodrine was administered out of parameters on 4/17/2023 at 6:00 PM when the systolic blood pressure was 126 administered by LVN A. *Midodrine was administered out of parameters on 4/18/2023 at 6:00 AM when the systolic blood pressure was 155 administered by LVN B. *Midodrine was administered out of parameters on 4/22/2023 at 12:00 PM when the systolic blood pressure was 125 administered by LVN C. *Midodrine was administered out of parameters on 4/22/2023 at 6:00 PM when the systolic blood pressure was 122 administered by LVN C. *Midodrine was administered out of parameters on 4/26/2023 at 6:00 AM when the systolic blood pressure was 127 administered by LVN B. *Midodrine was administered out of parameters on 4/29/2023 at 12:00 PM when the systolic blood pressure was 122 administered by LVN C. *Midodrine was administered out of parameters on 4/29/2023 at 6:00 PM when the systolic blood pressure was 124 administered by LVN C. *Midodrine was administered out of parameters on 4/30/2023 at 12:00 PM when the systolic blood pressure was 124 administered by LVN C. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 Level of Harm - Minimal harm or potential for actual harm *Midodrine was administered out of parameters on 5/04/2023 at 6:00 PM when the systolic blood pressure was 158 administered by LVN A. *Midodrine was administered out of parameters on 5/05/2023 at 12:00 PM when the systolic blood pressure was 122 administered by LVN C. Residents Affected - Some *Midodrine was administered out of parameters on 5/06/2023 at 12:00 PM when the systolic blood pressure was 122 administered by LVN C. *Midodrine was administered out of parameters on 5/07/2023 at 12:00 PM when the systolic blood pressure was 123 administered by LVN C. *Midodrine was administered out of parameters on 5/07/2023 at 6:00 PM when the systolic blood pressure was 122 administered by LVN A. *Midodrine was administered out of parameters on 5/10/2023 at 6:00 PM when the systolic blood pressure was 124 administered by LVN A. *Midodrine was administered out of parameters on 5/11/2023 at 6:00 AM when the systolic blood pressure was 123 administered by LVN B. *Midodrine was administered out of parameters on 5/11/2023 at 12:00 PM when the systolic blood pressure was 125 administered by LVN C. *Midodrine was administered out of parameters on 5/11/2023 at 6:00 PM when the systolic blood pressure was 126 administered by LVN A. *Midodrine was administered out of parameters on 5/17/2023 at 6:00 AM when the systolic blood pressure was 124 administered by LVN B. *Midodrine was administered out of parameters on 5/17/2023 at 12:00 PM when the systolic blood pressure was 127 administered by LVN C. *Midodrine was administered out of parameters on 5/18/2023 at 12:00 PM when the systolic blood pressure was 126 administered by LVN C. *Midodrine was administered out of parameters on 5/19/2023 at 12:00 AM when the systolic blood pressure was 126 administered by LVN B. *Midodrine was administered out of parameters on 5/19/2023 at 6:00 AM when the systolic blood pressure was 127 administered by LVN B. *Midodrine was administered out of parameters on 5/19/2023 at 12:00 PM when the systolic blood pressure was 129 administered by LVN C. *Midodrine was administered out of parameters on 5/20/2023 at 12:00 AM when the systolic blood pressure was 123 administered by LVN B. *Midodrine was administered out of parameters on 5/22/2023 at 6:00 PM when the systolic blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 pressure was 121 administered by LVN C. Level of Harm - Minimal harm or potential for actual harm *Midodrine was administered out of parameters on 5/23/2023 at 12:00 AM when the systolic blood pressure was 150 administered by LVN B. Residents Affected - Some *Midodrine was administered out of parameters on 5/23/2023 at 6:00 AM when the systolic blood pressure was 140 administered by LVN B. *Midodrine was administered out of parameters on 5/23/2023 at 12:00 PM when the systolic blood pressure was 123 administered by LVN C. *Midodrine was administered out of parameters on 5/26/2023 at 6:00 AM when the systolic blood pressure was 132 administered by LVN A. *Midodrine was administered out of parameters on 5/24/2023 at 6:00 AM when the systolic blood pressure was 124 administered by LVN B. *Midodrine was administered out of parameters on 6/06/2023 at 12:00 PM when the systolic blood pressure was 132 administered by LVN A. *Midodrine was administered out of parameters on 6/15/2023 at 6:00 PM when the systolic blood pressure was 124 administered by LVN A. *Midodrine was administered out of parameters on 6/16/2023 at 12:00 PM when the systolic blood pressure was 122 administered by LVN C. *Midodrine was administered out of parameters on 6/16/2023 at 6:00 PM when the systolic blood pressure was 124 administered by LVN A. *Midodrine was administered out of parameters on 6/17/2023 at 12:00 PM when the systolic blood pressure was 125 administered by LVN C. *Midodrine was administered out of parameters on 6/19/2023 at 6:00 AM when the systolic blood pressure was 123 administered by LVN B. *Midodrine was administered out of parameters on 6/21/2023 at 6:00 PM when the systolic blood pressure was 122 administered by LVN A. *Midodrine was administered out of parameters on 6/22/2023 at 6:00 PM when the systolic blood pressure was 122 administered by LVN A. *Midodrine was administered out of parameters on 6/28/2023 at 6:00 PM when the systolic blood pressure was 134 administered by LVN A. *Midodrine was administered out of parameters on 6/29/2023 at 12:00 PM when the systolic blood pressure was 129 administered by LVN C. 4. Record review of admission Record , dated 7/02/2023, revealed Resident #5 was a [AGE] year-old female, admitted on [DATE]. Diagnoses included hypotension and bradycardia [abnormally slow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 heartbeat]; and heart failure. Level of Harm - Minimal harm or potential for actual harm Record review of annual MDS assessment, dated 5/08/2023, revealed Resident #5's primary reason for admission was medically complex conditions. Other active diagnoses included: orthostatic hypotension. Residents Affected - Some Record review of Resident #5's Care Plan, revised on 7/04/2019, revealed a problem area of, Hypotension; associated interventions included, give medications as ordered, initiated 7/04/2019. Record review of Resident #5's Order Summary Report, dated 7/02/2023, revealed active orders for: Midodrine HCL, oral, tablet 5 MG, give one tablet by mouth three times a day for hypotension, hold for systolic greater than 120 or diastolic greater than 70; start date 2/07/2023. Record review of Resident #5's MAR for the months of April, May, and June 2023 revealed: *Midodrine was administered out of parameters on 4/03/2023 at 1:00 PM when the systolic blood pressure was 122 administered by [unnamed staff]. *Midodrine was administered out of parameters on 4/11/2023 at 7:00 AM when the systolic blood pressure was 125 administered by LVN F. *Midodrine was administered out of parameters on 4/11/2023 at 1:00 PM when the systolic blood pressure was 125 administered by LVN F. *Midodrine was administered out of parameters on 4/18/2023 at 7:00 AM when the systolic blood pressure was 132 administered by LVN D. *Midodrine was administered out of parameters on 4/19/2023 at 7:00 AM when the systolic blood pressure was 140 administered by LVN D. *Midodrine was administered out of parameters on 4/20/2023 at 7:00 PM when the systolic blood pressure was 124 administered by LVN A. *Midodrine was administered out of parameters on 4/21/2023 at 7:00 PM when the systolic blood pressure was 126 administered by LVN A. *Midodrine was administered out of parameters on 4/25/2023 at 7:00 PM when the systolic blood pressure was 121 administered by RN E. *Midodrine was administered out of parameters on 5/03/2023 at 7:00 PM when the systolic blood pressure was 123 administered by LVN A. *Midodrine was administered out of parameters on 5/08/2023 at 7:00 AM when the systolic blood pressure was 122 administered by LVN D. *Midodrine was administered out of parameters on 5/14/2023 at 7:00 AM when the systolic blood pressure was 128 administered by LVN D. *Midodrine was administered out of parameters on 5/30/2023 at 1:00 PM when the systolic blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 pressure was 122 administered by LVN D. Level of Harm - Minimal harm or potential for actual harm *Midodrine was administered out of parameters on 6/01/2023 at 7:00 AM when the systolic blood pressure was 132 administered by LVN D. Residents Affected - Some *Midodrine was administered out of parameters on 6/07/2023 at 1:00 PM when the systolic blood pressure was 128 administered by LVN D. *Midodrine was administered out of parameters on 6/07/2023 at 7:00 PM when the systolic blood pressure was 126 administered by LVN A. *Midodrine was administered out of parameters on 6/20/2023 at 7:00 PM when the systolic blood pressure was 126 administered by LVN A. *Midodrine was administered out of parameters on 6/26/2023 at 7:00 PM when the systolic blood pressure was 124 administered by LVN A. *Midodrine was administered out of parameters on 6/29/2023 at 1:00 PM when the systolic blood pressure was 136 administered by LVN D. In an interview on 7/02/2023 at 1:30 PM, LVN G stated she reviewed medications prior to pulling them from the container or blister pack. LVN G stated she would obtain vital signs for the medications as per the PCP orders. LVN G stated midodrine is a medication that helps bring up blood pressure. LVN G stated the medication would be held if the blood pressure were too high. LVN G stated that a resident could have headaches or become hypertensive [high blood pressure] if midodrine were given to a resident when their blood pressure was high. LVN G stated she could not recall which residents received midodrine, she would need to review the MARs or Order Summary for each resident. In an interview on 7/02/2023 at 4:45 PM, LVN A stated midodrine is a medication that is given only to a few of the residents. LVN A stated midodrine is to help residents with low blood pressure. LVN A stated the PCP or pharmacist set the desired parameters. LVN A stated he would hold any medication if the residents' vital signs were out of the PCP's parameters. LVN A stated he could not recall any instance of administering medication out of parameters set by the PCP. LVN A stated he documented the reason code in the MAR when a medication was held or omitted. LVN A stated it was possible he incorrectly documented a medication as given, when the parameters indicated the medication should be held. LVN A stated he could not recall any residents that required midodrine ever having symptoms of high blood pressure after medication administration. LVN A stated he tried to accurately document in the moment, but sometimes the residents' behaviors could be distracting if they were violent, loud, or intrusive . In an interview on 7/02/2023 at 5:50 PM, the DON stated the symbol > indicated greater than and the symbol < indicated less than. The DON stated these symbols were used on the MAR when a medication has parameters to hold if the vital signs or blood sugars are either too high or too low for safe administration of a medication. The DON stated the PCP set the parameters for those medications. The DON stated midodrine was a medication that increase low blood pressure. The DON stated that midodrine should not be administered if the blood pressure or heart rate was already at specified levels as this could put the resident at risk for adverse effects such as stroke. The DON stated each nurse was trained to take the residents vital signs immediately prior to administering medications to the resident. The DON stated the MARs were reviewed each day prior to the morning meeting. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete stated the MARs were reviewed to track refusals or non-compliance. The DON stated he had not realized midodrine was being given out of PCP established parameters. The DON stated he would have to further review the records for residents whose medications had parameters set by the PCP. Review of Medication Administration policy, dated 10/24/2022, revealed under the heading Policy Explanation and Compliance Guidelines, step 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. In step 14. Administer medication as ordered . In step 17.record the vital signs on the MAR. Event ID: Facility ID: 675409 If continuation sheet Page 11 of 11

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0760GeneralS&S Epotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

FAQ · About this visit

Common questions about this visit

What happened during the July 2, 2023 survey of WINDSOR MISSION OAKS?

This was a inspection survey of WINDSOR MISSION OAKS on July 2, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WINDSOR MISSION OAKS on July 2, 2023?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.