Windsor Mission Oaks

In the surveyor’s words

From the most serious findings on record at Windsor Mission Oaks, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 8, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Apr 26, 2022

  Based on observation, interview, and record review the facility failed to ensure the residents right to be free from abuse for 1 of 4 residents (Resident #1) reviewed for abuse, in that; The facility failed to ensure Resident #1, who was on a pureed diet, was provided the correct diet and supervision when Resident was fed and consumed a regular diet on [DATE] which resulted in a choking event, loss of consciousness requiring the [MEDICATION(S)] maneuver, back thrusts, and CPR before being revived and receiving treatment at the hospital. This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 8:25 p.m. […]

• No harm, potential for more than minimal, widespreadF812Jun 27, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812May 8, 2024

  Based 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. Cook 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. Cook B wore a wristwatch on his arm while preparing food in the kitchen. 5. […]

• No harm, potential for more than minimal, widespreadF812Mar 31, 2023

  Based 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 Cook 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. The findings were: 1. […]