All citations for Windsor Mission Oaks

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Windsor Mission Oaks

Last standard health inspection on record

June 27, 2025

Showing 26 to 50 of 52 citations

  1. No harm, with potential for more than minimal harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0552, Resident Rights Deficiencies. Inspection of June 27, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 28, 2025).

  2. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of June 27, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 28, 2025).

  3. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0693, Quality of Life and Care Deficiencies. Inspection of June 27, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 28, 2025).

  4. No harm, with potential for more than minimal harm

    Install an approved automatic sprinkler system.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0351, Smoke Deficiencies. Inspection of June 27, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 28, 2025).

  5. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 24, 2024).

  6. No harm, with potential for more than minimal harm

    Respond appropriately to all alleged violations.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 24, 2024).

  7. No harm, with potential for more than minimal harm

    Reasonably accommodate the needs and preferences of each resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0558, Resident Rights Deficiencies. Inspection of May 8, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  8. No harm, with potential for more than minimal harm

    Keep residents' personal and medical records private and confidential.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0583, Resident Rights Deficiencies. Inspection of May 8, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  9. No harm, with potential for more than minimal harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of May 8, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  10. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0726, Nursing and Physician Services Deficiencies. Inspection of May 8, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  11. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0758, Pharmacy Service Deficiencies. Inspection of May 8, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  12. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of May 8, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  13. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of May 8, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  14. No harm, with potential for more than minimal harm

    Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0929, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 8, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 9, 2024).

  15. No harm, with potential for more than minimal harm

    Keep residents' personal and medical records private and confidential.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0583, Resident Rights Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  16. No harm, with potential for more than minimal harm

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0640, Resident Assessment and Care Planning Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  17. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  18. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  19. No harm, with potential for more than minimal harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  20. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0849, Administration Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  21. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0511, Services Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  22. No harm, with potential for more than minimal harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  23. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 31, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 1, 2023).

  24. No harm, with potential for minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level C.

    Fire safety citation K-0521, Services Deficiencies. Inspection of June 27, 2025. Found during a standard inspection.

    No follow-up visit needed.

  25. No harm, with potential for minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level C.

    Fire safety citation K-0521, Services Deficiencies. Inspection of May 8, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.