Windsor Mission Oaks

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 linen carts (LC #1 and LC #2) reviewed for infection control. The facility failed to ensure clean linen was stored properly on the 100 hall. The facility failed to ensure clean linen was stored properly on the 200 hall. These deficient practices could place residents at risk of infection and decline in health.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to label, date, and seal an opened bag of toasted oats cereal and three opened bags of pasta in the dry storage room. 2. The facility failed to store a mop, broom, and multiple mop heads in a sanitary manner in the utility closet.3. The facility failed to store three cases of water bottles off the floor in the storage area outside the kitchen.4. DA P failed to cover all his facial hair with a facial hair restraint while preparing food in the kitchen on 06/29/2025. These failures could place residents who received meals and snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Residents #30 and #41) reviewed for incontinent care, in that: 1. The facility failed to ensure CNA I thoroughly cleaned Resident #30 while providing incontinent care. 2. The facility failed to ensure CNA N used the right technique to clean Resident #41 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that CNAs were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 2 of 3 residents (Residents #30 and #41 ) by 2 of 8 CNAs (CNA I and CNA N) reviewed for competent staff, in that: 1. The facility failed to ensure CNA I thoroughly cleaned Resident #30 while providing incontinent care. 2. The facility failed to ensure CNA N used the right technique to clean Resident #41 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 3 nurse medication carts (Hall 500 medication cart) reviewed for security and supervision and for one of one medication room reviewed for safe storage of medications requiring refrigeration. 1. The facility failed to ensure that LVN-R did not leave out a vial of insulin on top of the medication cart and leave that medication cart unlocked and out of line of sight when she went inside Resident #15's room to administer his medication.2. The facility failed to store medications within recommended temperature range in the medication refrigerator in the medication storage room. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 6 residents (Residents #23, #41 and, #46)) reviewed for infection control, in that: 1. While providing transfer assistance for Resident #23, CNA H failed to use proper infection control. 2. While providing catheter care for Resident #41, CNA N and CNA M failed to use proper infection control. 3. While providing incontinent care for Resident #46, CNA K failed to use use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 4 of 5 units (unit 100, 200, 300, and 400) observed for environment, in that: 1. The facility failed to ensure furniture was in a good state of repair in resident rooms. 2. The facility failed to secure chemical cleaners. 3. The facility failed to ensure outside doors were in a good state of repair. These deficient practices could place residents at risk of a diminished quality of life due to an unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 3 of 5 units (unit 100, 300, and 400) reviewed for effective pest control in that: Numerous flies were observed throughout the investigation period in and around units 100, 300, and 400. This deficient practice could result in diminished quality of life for residents die to living in an environment with pests.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he preferred for 1 of 3 Residents (Resident #91) whose records were reviewed for informed consent. The facility failed to ensure psychoactive medication consents for Resident #91's were signed and dated by his Guardian for the use of Zyprexa (antipsychotic medication), Haldol (antipsychotic medication), Perseris (atypical antipsychotic), Zoloft (anti-depressant) and Trazodone (anti-depressant). This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 29 residents (Resident #49) reviewed for care plans. 1. The facility failed to revise Resident #49's comprehensive care plan to include a diagnosis of depression.2. The facility failed to revise Resident #49's comprehensive care plan to include the resident's use of a psychotropic medication (Sertraline). These failures could place residents at risk of not receiving appropriate interventions to meet their current health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #9 ) reviewed for enteral feeding (method to provide nutrition and fluids directly into digestive tract via a feeding tube): LVN Q failed to flush Resident #9's enteral feeding tube per physician's orders. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours to the State agency for 2 of 9 residents (Residents #1 and #5) reviewed for failure to report. 1. The facility did not report an allegation of misappropriation of property for Resident #1 to the State Agency. 2. The facility did not report an allegation of misappropriation of property for Resident #5 to the State Agency. This failure could place residents at risk of abuse, neglect, or misappropriation of resident property.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident property for 2 of 9 residents (Residents #1 and #5) reviewed for the investigation of allegations. 1) The facility did not investigate when Residents #1 reported an allegation of misappropriation of property. 2) The facility did not investigate when Residents #5 reported an allegation of misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #21) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #21 who eloped from the facility on 05/02/24. An Immediate Jeopardy (IJ) was identified as past non-compliance on 05/07/24. The non-compliance began on 05/02/24 and ended on 05/04/24. The facility had corrected the non-compliance before the survey began on 05/05/24. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. [NAME] A was did not wear a facial hair restraint while engaged in food preparation and service. 2. There were ten thermometers in the hand-washing sink. 3. In the reach-in cooler there was a 5-lb. bag of Mozzarella cheese past its use-by date and containers of thickened juice and milk without labels indicating a use-by date. 4. [NAME] B wore a wristwatch on his arm while preparing food in the kitchen. 5. The chemical sanitizing solution in the dish machine did not reach the minimum ppm required. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 3 of 3 residents (Residents #43, #79, and #91) reviewed for medications, in that: LVN LL pre-poured medications for Residents #43, #79, and #91 and stored them in the top drawer of the medication cart. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of their medications as ordered.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 5 resident hallways reviewed for environmental conditions ensure in that: The facility failed to ensure four resident hallways did not have hallway side rails that were not clean and sticky to the physical touch. This deficient practice could place residents at risk of living in an unsanitary environment.

Inspectors wroteBased on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 1 building reviewed for pest control. The facility did not have an effective pest control program to eradicate the flies in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff members were educated on the rights of the resident and the responsibilities of the facility to properly care for its residents for 4 of 22 staff (CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist) reviewed for training requirements in that: The facility failed to ensure four staff which included: CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist received the required training on resident rights during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff members were educated on abuse, neglect, and exploitation related to resident care for 5 (CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist) of 22 staff reviewed for training requirements in that: The facility failed to ensure that five staff which included: CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist received the required training on abuse/neglect/exploitation during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 4 residents (Resident #94) reviewed for reasonable accommodations and preferences, in that: The facility failed to ensure Resident #94's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #42) reviewed for privacy, in that: CNA C and CNA D did not close Resident #42's window privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 resident (Resident #29) reviewed for incontinent care, in that: While providing incontinent care for Resident #29, CNA E did not clean between Resident #29's buttocks'' cheeks and CNA E did not use the right technique to clean Resident #29's penis. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 4 residents (Resident #29) by 1 of 4 certified staff (CNA E) reviewed for competent staff, in that: 1. While providing incontinent care for Resident #29, CNA E did not clean between Resident #29's buttocks'' cheeks and CNA E did not use the right technique to clean Resident #29's penis. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 1 of 4 residents (Resident #70) reviewed for accuracy of medical records in that: The facility failed to ensure Resident's#70 order of Lorazepam 0.5 mg every 4 hours X 2 doses. However, the order did not have a stop date.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #29) reviewed for infection control, in that: CNA E did not change her gloves or wash her hands after providing incontinent care for Resident #29 These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review revealed the facility failed to store, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. Kitchen staff stacked plates that were wet for meal service. 2. Kitchen staff failed to keep the two -compartment oven clean. 3. Kitchen staff failed to store chemicals off the floor. 4. Kitchen staff failed to cover 4 trays of regular diet pumpkin pie dessert plates and 1 tray of puree pumpkin pie dessert cups. 5. The DM and [NAME] O failed to ensure their hairnet covered all of their hair. These deficiencies could affect residents who ate meals prepared from the kitchen and could contribute to the spread of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 24 residents (Resident #7) reviewed for advanced directives, in that: The facility failed to ensure Resident #7's Out-of-Hospital Do Not Resuscitate (OOHDNR) was signed, by the responsible party, on [DATE] at the bottom of the form. This deficient practice could place residents at-risk for residents' rights not being honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 residents (Resident #19) whose records were reviewed for falls, in that: Staff failed to identify Resident #19's hoarding behavior as a safety hazard and to implement safety measures. This deficient practice could affect any resident and contribute to avoidable falls.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 7 of 24 residents (Residents #8, #12, #21, #52, #75 #108, #115) reviewed for pests, in that: Facility failed to ensure their pest control program was thoroughly working in all areas of the facility This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 resident (Resident #57) reviewed for privacy, in that: CNA A and CNA B did not completely close Resident #57's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on the interview and record review, the facility failed to transmit the resident assessment within the required time frame for 1 of the 3 discharged residents reviewed for data encoding and transmission. (Resident # 120). The facility did not submit a discharge not anticapated MDS for Resident # 120. This failure could put residents discharged from the facility at risk of not having their assessments transmitted acurately .

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 28 residents (Residents #48 and, #33) whose assessments were reviewed, in that: 1. Resident #48's Quarterly MDS incorrectly documented the resident as receiving an insulin injection. 2. Resident #33's Quarterly MDS did not indicate he had experienced a significant weight loss. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights meet a resident's mental and psychosocial needs for 1 of 6 Residents (Resident #19) whose records were reviewed for care plans. Resident #19's Care Plan did not reflect she was a hoarder affecting her daily living. This deficient practice could affect any resident and contribute to resident needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #57) reviewed for incontinent care, in that: While providing incontinent care for Resident #57, CNA A used a back to front motion to clean Resident #57's genitals. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 5 residents (Resident #76) reviewed for hospice services, in that: Facility did not ensure Resident #76's hospice records were a part of their records in the facility This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly including 1 of 2 garbage containers, in that: The facility staff failed to keep the sliding door closed to prevent the harborage and feeding of pests. This deficient practice could affect any resident and contribute to the spread of diseases and infections.