A list of the most recent deficiencies for Windsor Mission Oaks. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-07-02 | 2023-07-03 | Y |
| 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. | Health | 2023-03-31 | 2023-04-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-31 | 2023-04-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-03-31 | 2023-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-31 | 2023-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-31 | 2023-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-31 | 2023-04-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-31 | 2023-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-31 | 2023-04-01 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-31 | 2023-04-01 | N |
| 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. | Health | 2023-03-31 | 2023-04-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-31 | 2023-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-30 | 2023-04-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-30 | 2023-04-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-30 | 2023-04-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-30 | 2023-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-30 | 2023-04-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-14 | 2022-05-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-14 | 2022-05-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-14 | 2022-05-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-26 | 2022-05-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-26 | 2022-05-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-26 | 2022-05-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-26 | 2022-05-16 | Y |
| 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. | Health | 2022-01-21 | 2022-02-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-21 | 2022-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-02-10 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-27 | 2022-02-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-27 | 2022-02-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-02 | 2021-12-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-02 | 2021-10-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-02 | 2021-10-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-28 | 2020-11-12 | N |
| 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. | Health | 2020-10-28 | 2020-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-28 | 2020-11-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-28 | 2020-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-28 | 2020-11-12 | N |
| 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. | Health | 2020-10-28 | 2020-11-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-10-27 | 2020-10-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-10-27 | 2020-10-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-10-27 | Not Fixed | N |
