Windsor Mission Oaks

Penalties

• May 8, 2024 — Fine ($10,842)

Inspection findings

1. Jun 12, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 13, 2026 · CMS health inspection

2. Jun 27, 2025 Health · 14 findings
   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

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

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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.

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0726 Nursing and Physician Services Deficiencies

     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.

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Jun 28, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Jun 28, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jun 28, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

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

     CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Jun 28, 2025 · CMS fire safety

3. May 23, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected May 24, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected May 24, 2024 · CMS health inspection

4. May 8, 2024 Health · 19 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected May 9, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 4, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

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

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0726 Nursing and Physician Services Deficiencies

     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.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0942 Resident Rights Deficiencies

     Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0943 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

     Corrected May 9, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

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

     Corrected May 8, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected May 9, 2024 · CMS fire safety

5. Mar 31, 2023 Health · 16 findings
   • Not serious Scope/severity E

     F0578 Resident Rights Deficiencies

     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.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0640 Resident Assessment and Care Planning Deficiencies

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

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity C

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     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.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Apr 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 1, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 1, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

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

     Corrected Apr 1, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

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

     Corrected Apr 1, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Apr 1, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAIRD, DANIEL — managing control - governing body, NOT APPLICABLE, since 04/13/2021
• CLAPP, BARBARA — managing control - governing body, NOT APPLICABLE, since 06/01/2021
• CORTESE, DAREN — managing control - governing body, NOT APPLICABLE, since 08/10/2021
• DEKOWSKI, DONOVAN — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• DEKOWSKI, DONOVAN — adp of the snf, NOT APPLICABLE, since 04/01/2022
• DIAZ, CHRISTOPER — adp of the snf, NOT APPLICABLE, since 01/01/2025
• DIAZ, CRIS — managing control - governing body, NOT APPLICABLE, since 11/18/2020
• GIBSON, PATRICIA — managing control - governing body, NOT APPLICABLE, since 08/01/2021
• GIVENS, LAURA — adp of the snf, NOT APPLICABLE, since 07/01/2015
• JOHNSON, NICHOLAS — adp of the snf, NOT APPLICABLE, since 01/01/2025
• JURADO, JORGE — corporate officer, NOT APPLICABLE, since 10/13/2023
• JURADO, JORGE — managing control - governing body, NOT APPLICABLE, since 10/13/2023
• MANDELBAUM, ELLIOT — managing control - governing body, NOT APPLICABLE, since 01/01/2025
• OTAZO, JULIO — managing control - governing body, NOT APPLICABLE, since 05/25/2022
• PALMER, ROBIN — managing control - governing body, NOT APPLICABLE, since 11/18/2020
• RAMIREZ, HERMELINDO — operational/managerial control, NOT APPLICABLE, since 11/08/2023
• RAMIREZ, HERMELINDO — adp of the snf, NOT APPLICABLE, since 11/08/2023
• 300 S ROOSEVELT AVENUE LLC — adp of the snf, NOT APPLICABLE, since 04/01/2022
• CSV RHEA MANAGEMENT HOLDCO, LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• DWD TX HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• REG HG OPCO 1, LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• REG HG OPCO LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• REG OPERATOR HOLDCO LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• REGENCY IHS CLINICAL CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 04/01/2022
• REGENCY IHS MASTER TENANT LLC — adp of the snf, NOT APPLICABLE, since 04/01/2022
• REGENCY IHS OF WINDSOR MISSION OAKS, LLC — direct ownership interest, NOT APPLICABLE, since 04/01/2022
• REGENCY IHS OF WINDSOR MISSION OAKS, LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• REGENCY IHS OF WINDSOR MISSION OAKS, LLC — adp of the snf, NOT APPLICABLE, since 11/14/2024
• REGENCY IHS REHAB LLC — adp of the snf, NOT APPLICABLE, since 04/01/2022
• REGENCY INTEGRATED HEALTH SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• REGENCY INTEGRATED HEALTH SERVICES LLC — adp of the snf, NOT APPLICABLE, since 11/14/2024
• REGENCY INTEGRATED HEALTH SERVICES LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• REGENCY TEXAS HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 04/01/2022
• VAL VERDE COUNTY HOSPITAL DISTRICT — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• VAL VERDE COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 04/01/2022
• VAL VERDE COUNTY HOSPITAL DISTRICT — adp of the snf, NOT APPLICABLE, since 04/24/2025