Brookdale Windsor

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Unlawful eviction

An Office meeting was conducted today, 07/30/2025, in the Santa Rosa Regional Office. LPA Robert Frank delivered investigation findings to Jeannette Kinney, Executive Director. Licensing Program Analyst (LPA) Robert Frank conducted a complaint investigation regarding the allegations listed above. The complaint alleges that after the resident (R1) was sent to the hospital on 4/11/2025 for medical issues and that the resident was denied the ability to return to the facility. Complainant indicated the facility did not provide a thirty (30) day eviction notice or seek approval from Community Care Licensing (CCL) to serve a three (3) day notice. Continued on 9099-C... Substantiatedthe state’s words, verbatim · CDSS document, Jul 30, 2025 · control 21-AS-20250415140750

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not seek timely medical care for resident Facility staff did not ensure resident’s room was maintained clean Facility staff did not provide explanation of services to be provided at the new level of care to resident's responsible person Facility staff did not provide an itemization of charges to resident's responsible person

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Jeanette Kinney, Administrator. Complaint alleges facility staff did not seek timely medical care for resident. Complainant alleges that resident (R1) fell in their room resulting in head injury but facility did not seek medical attention. During investigation, LPA reviewed chart notes of R1. Chart notes indicate that R1 was found at 0800 laying on the floor, they had hit their head on the shower floor. A head bandage was applied by staff and pain medication administered at 0856. R1’s elbow had a hematoma forming and their bottom area was not examined due to the immediate attention their head needed. Hospice was notified 3 times: an initial call, a follow up call, and a third call to see if the facility should send the resident out to the ER. Notes indicate the bleeding from R1’s head was not stopping, despite keeping pressure to the back right side of theithe state’s words, verbatim · CDSS document, May 30, 2025 · control 21-AS-20250205134706

Allegation investigated: Medications not dispensed as prescribed

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegation and met with Jeanette Kinney, Administrator. Complaint alleges facility did not dispense medications as prescribed. Complainant states on 2/20/25 resident ( R1) was discharged from a facility to Brookdale Windsor. On 2/18/25 Brookdale Windsor Health and Wellness Director, Tina Worton (HWD) received a copy of discharge instructions and medications for R1. However, HWD was not present at the facility on 2/20/25 or 2/21/25 and so R1’s medications from discharge were not added to their current medications list, resulting in R1 not receiving their updated medication. During investigation, LPA reviewed staffing schedule for facility. Schedule shows that HWD was off duty on 2/20/25 and 2/21/25. During investigation, LPA conducted interviews. Staff indicated to LPA that the Continued on 9099C... Unsubstantiatedthe state’s words, verbatim · CDSS document, May 30, 2025 · control 21-AS-20250227092720

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure resident was free of scabies Due to staff neglect, resident sustained a pressure injury

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Jeanette Kinney, Administrator. Complaint alleges staff did not ensure resident was free of scabies. Complainant states that resident (R1) was diagnosed with scabies and that the facility did not notify the appropriate parties such as other residents, staff, and R1’s responsible party. During investigation, LPA reviewed R1’s charting progress notes, incident reports, medical records and hospital discharge papers. R1 was on a showering schedule of every Sunday and Wednesday. However, progress notes indicate R1 refused 7 of the 9 scheduled showers in the month directly preceding the date of the allegation of scabies. So, staff were not looking at the bare skin of the resident because the resident was refusing showers. Continued on 9099C... Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 1, 2024 · control 21-AS-20240812081037

Allegation investigated: Facility did not provide resident with daily activities Facility did not follow Admission Agreement Facility shared resident's confidential information with an unauthorized person Facility forced resident to participate in memory testing without consent Facility did not ensure that resident was adequately fed Personal Rights Facility did not safeguard resident's personal items Facility did not seek medical attention for the resident in a timely manner

At approximately 9:40am, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Jeanette Kinney, Administrator. Complaint alleges facility did not provide resident with daily activities. Complainant states resident was promised activities such as driven outings in the van to see the sites, regular classes, happy hours, regular entertainment events and services such as an onsite hairdresser. Complainant also states that Brookdale suspended activities very soon after resident moved into the facility due to COVID. However, the suspension of large groups of people congregating is in observance of the Center for Disease Control guidelines pertaining to COVID. Furthermore, per LPA interviews during investigation, three [3] out of three [3] residents report there are activities that are provided. Activities include crafts, bingo, happy hours and music. The residents sign up at the front desk for the outings and that ithe state’s words, verbatim · CDSS document, Aug 20, 2024 · control 21-AS-20240426155018

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident developed a pressure injury while in care. Staff are not following resident's doctor's orders. Staff does not provide resident with dry linen.

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Health and Wellness Director, Tina Worden. During the course of the investigation, the Department conducted interviews and requested and reviewed documents. Resident developed a pressure injury while in care – Complaint alleges that resident developed a pressure injury that was discovered by their doctor on 11/6/2023. Complaint indicates that facility staff should have observed the injury when providing care needs and reported it. Per review of documents, Resident 1 (R1) received a shower on 11/4/2023 and staff did not observe any skin changes to the resident’s heel. Per progress notes, resident was also given a shower on 11/5/2023 and staff noted that skin card was clear. There were no notes on 11/5/2023 or 11/6/2023 referencing a change in resident’s skin condition. Continued on LIC9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 15, 2024 · control 21-AS-20231117090301

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.