Brookdale Windsor

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Loera arrived on 8/28/2026 for an unannounced inspection to follow up on substantiated complaint findings, Complaint # 21-AS-20250205134706. On May 30, 2025, the Department concluded a complaint investigation regarding the following allegations: Facility staff did not seek timely medical care for resident. The licensee was cited for California Code of Regulations (CCR) Advanced Directives and Requests Regarding Resuscitative Measures 87469(c)(3). During the July 30, 2025, office meeting in the Santa Rosa Regional Office, the licensee was informed that a civil penalty might be assessed. Assessment of Civil Penalty is allowable based on Health and Safety Code 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not seeking timely medical attention after a fall which resulted in a serious head injury which required sutures. Today, 8/28/2026, the Department will be issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided to Health and Wellness Director, Tina Worden and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 28, 2026

Type of visit: Required - 1 Year

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection. Executive Director (ED) Jeanette Kinney arrived at approximately 9:30 AM. Brookdale Windsor is Licensed as a Residential Care Facility for the Elderly (RCFE). The Facility has a plan of operation for dementia care and programming on file. The facility has an approved fire clearance and total capacity for eighty (80) non-ambulatory residents. The facility has an approved hospice waiver for ten (10) residents. The facility is a multi-level building with a large patio and garden area between the two (2) resident wings. LPA was informed that there were sixty-five (65) Residents in care. At approximately 9:45 AM LPA reviewed Facility Staff Roster and found that all staff members were background cleared and associated to the facility per regulation. At approximately 10:20 AM, LPA reviewed nine (9) resident files. Nine (9) of nine (9) resident files were observed to be well organized and thorough with all required documentation including current Service Plans and Physician's Reports. LPA reviewed eight (8) staff files. Eight (8) of eight (8) staff files were observed with all required documentation including First Aid and CPR certification and proper training documentation. LPA audited Medication for nine (9) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items. Continued on 809-C... ,,,Continued from 809 Jeannette Kinney’s Administrator Certification 7016943740 is current with an expiration date of 8/12/2026. LPA is requesting the following documents be submitted to CCLD by 6/9/2026: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Updated Liability Insurance Policy LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Kinney. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 8, 2026

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... Substantiated ...Continued from 9099 During investigation, LPA reviewed Chart Notes. The first Chart Note dated 4/10/2025, 11:30 AM stated that resident R1 was sent to Sutter Hospital Santa Rosa for “dangerous high glucose level”. The charting notes further indicated that R1 was showing signs of anxiety and stress. The 911 call was initiated by R1’s third party Behavior Specialist/BSN (BSN1). The next “Alert Charting Note” text dated 4/10/2025 22:58 states, “Resident called about ten 10 times, requesting to come back to the community. According to the ED, resident isn’t allowed to come back at this time, until they (R1) receive proper treatment, prior to returning”. LPA interviewed Executive Director (ED) Jeannette Kinney at 2:16 PM on 4/22/2025. When asked, “was R1 denied a return to the facility?”, ED Kinney responded, “Yes, we couldn’t control R1’s behaviors.” Based on interviews and review of care plan, R1 transferred from another Brookdale community and their behaviors were known and documented upon admission to Brookdale Windsor. Based on LPA’s interview, record review and express admission the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, 87468.2(a)(20) are being cited on the attached 9099D. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-9099D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Kinney. Signature on form confirms receipt of documentsthe state’s words, verbatim · CDSS document, Jul 30, 2025 · control 21-AS-20250415140750

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Jul 31, 2025

Additional Personal Rights of Residents in Privately Operated Facilities(a)In addition to the rights listed in Section 87468.1, ...(20)To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict... This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that resident R1 was not allowed to return to the facility after a hospital emergency room visit which posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: Facility to submit an LIC 9098 to Community Care Licensing self certifying that they have reviewed and CCR 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities and CCR 87224 Eviction Procedures by POC due date of 7/31/2025.

Type of visit: Office

An Office meeting was conducted today, 07/30/2025, in the Santa Rosa Regional Office. The following individuals were present in the meeting: Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Victoria Bertozzi, Licensing Program Analyst, Robert Frank, Jeannette Kinney, Executive Director, Tina Worden, Health and Wellness Director, Grace Ndomo, District Director of Operations, Mindy Podraza, District Director of Clinical Services, Joel Goldman, outside counsel. Additionally, Tabatha Clark, Brookdale’s Divisional Director of Clinical Operations attended via Teams meeting. The purpose of the office meeting was to hold an Informal meeting to address areas of concern identified by the Department. -Personal Rights/Wrongful Evictions -Seeking Timely Medical Care for Residents The issuance of an Civil Penalty is under review. The Licensee is being informed that an Civil Penalty might be assessed based on a violation that the Department determines constitutes the facility not seeking timely medical care for a resident, as defined in Title 22, Division 6, Chapter 8, Article 08, Resident Assessments, Fundamental Services and Rights, 87469 Advanced Directives and Requests Regarding Resuscitative Measures Deficiencies Cited on Complaint Control Number 21-AS-20250415140750.the state’s words, verbatim · CDSS document, Jul 30, 2025

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 their Continued on 9099C... Substantiated Continued from 9099... head. Case Manager arrived at the facility at 0945 advising facility that hospice was on the way. After hospice team arrived, they made the decision to have R1 sent to the ER by ambulance. LPA’s review of chart notes indicate that R1 experienced an injury unrelated to the reasons for which they were on hospice. However, facility waited almost 2 hours, with R1’s head continuously bleeding, before sending to the hospital. Additionally, the facility waited for hospice to make the determination to send to the hospital, they themselves did not make the determination. Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Complaint alleges facility staff did not ensure resident’s room was maintained clean. Complainant alleges facility did not properly clean R2’s room and that remnants of fecal incontinence were left unattended. During investigation, LPA reviewed Administrator’s email pertaining to the cleaning of R2’s room, email shows that Administrator acknowledged that staff needs to “clean things up much better.” Additionally, in email, Administrator acknowledges that “if maintenance is not available to clean up, then the facility needs to find another person that can clean up right away.” Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Complaint alleges facility staff did not provide notification of or explanation of services to be provided at the new level of care to resident's responsible person and that facility staff did not provide an itemization of charges to resident's responsible person. During investigation, LPA reviewed billing statements provided to R2’s responsible party from the facility. LPA also reviewed email exchange between facility’s Health and Wellness Director (HWD) and R2’s responsible party. Increase in charges for new level of care were implemented January 1, 2025. However, R2’s responsible party claims they were not made aware of the changes in level of care needed nor that a new level of care was being provided. LPA reviewed R2's three most recent care plans and found care plan from December 24, 2024 to indicate increased level of care needed for R2. However, none of the care plans were signed by R2’s responsible party. Facility did eventually provide Continued on 9099C(2)... Continued from 9099C... explanation of fees and itemization of fees to resident’s responsible party on January 26, 2025. However, facility could not show or provide LPA with proof of initial notification. Per Health and Safety Code 1569.657(a), any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. However, facility could not provide LPA proof of notification sent to R2's responsible party within two [2] business days after initially providing services at the new level of care. Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, May 30, 2025 · control 21-AS-20250205134706

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Jun 2, 2025

87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident...experiences a medical emergency, facility staff shall do one of the following: (3) Specifically for a terminally ill resident that is receiving hospice services...and is experiencing a life-threatening emergency... not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement is not met as evidenced by: Based on LPA’s record review, the licensee did not comply with the section cited above in that facility did not immediately telephone emergency response for R1’s injury that was not directly related to the expected course of the resident’s terminal illness, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Facility to submit plan to conduct in-service hospice care and emergency procedures training for all direct care staff and Med Techs in the amount of no less than 1 hour by plan of correction due date. Facility to complete training for all direct care staff and Med Techs no later than 6/20/25. Completed training sign in sheet to be sent to CCL by no later than 6/20/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 6, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: as evidenced by: Based on LPA’s record review, the licensee did not comply with the section cited above in that facility did not properly R2’s room, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Facility to submit LIC9098 self-certifying all resident rooms will be kept in clean, safe, and sanitary conditions and that sufficient staff will be on duty to ensure as such.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Jun 20, 2025

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care... This requirement is not met as evidenced by: Based on LPA’s record review and interview, the licensee did not comply with the section cited above in that facility did not provide R2’s responsible party written notice of rate increase within two business days after initially providing services at the new level of care which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Facility to submit LIC9098 self-certifying that they will notify in writing residents' or residents' responsible party within 2 days of any change of level of care needs cost by plan of corrections due date.

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

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... Unsubstantiated Continued from 9099... procedure when processing a medication change or new medication is to first obtain signed doctor’s orders before faxing to Consonus, whether or not HWD is present at facility. LPA also reviewed medication list and MAR for R1. LPA reviewed start dates of medications identified on discharge papers to be administered daily. List shows medications ordered on 2/20/25 but not given until 2/21/25 or 2/23/25 for Atorvastatin and Salon Pas. However, during investigation, LPA was provided copies of Brookdale's Pharmacy Service Agreement and the Consonus Pharmacy Customer Agreement signed by R1’s responsible party. Noted on the Consonus Pharmacy Customer Agreement is a handwritten addition indicating that Brookdale would only use Consonus for R1 in the cases of over-the-counter medication or urgent/emergency medications. Admin clarified with LPA that even in the cases of using Consonus for urgent medications, Brookdale must still provide the family with an opportunity to provide Brookdale the medication even though they signed the Consonus Pharmacy Customer Agreement. Admin advised Brookdale still must wait the two [2] days indicated in the Pharmacy Service Agreement, because some people don’t have a co-pay through their own pharmacy such as the V.A. and/or Kaiser, but through Consensus they have to pay a shared cost. Per LPA record review and interview, there was delay in R1 receiving the new medications prescribed at discharge; however, it is unclear if the facility was following their written protocol, allowing the responsible party to obtain the prescription prior to using Consonus or if there was a delay due to the absence of the HWD. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Note: LPA clarified protocols with facility to ensure there are not unnecessary delays in the future with residents’ medications being administered timely. Exit interview conducted with Administrator and a copy of this report given.the state’s words, verbatim · CDSS document, May 30, 2025 · control 21-AS-20250227092720

Type of visit: Required - 1 Year

At approximately 8:35 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required inspection and was greeted by Dinning Room Director, Dynine Lesley. Health and Wellness Director (HWD) Tina Worden arrived at 9:50 AM. Executive Director (ED) Jeanette Kinney arrived at 10:30 AM from a previously scheduled appointment. Brookdale Windsor serves older adults in Assisted Living. The Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for eighty (80) non-ambulatory residents. Facility has an approved hospice waiver for ten (10) residents. The facility is a multi-level building with a large patio and garden area between the two (2) resident wings. Upon arrival, LPA was informed that there were fifty-six (56) Residents in care. At approximately 10:00 AM LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 10:45 AM LPA toured the facility with HWD Worden . The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a variety of menu options for the residents at each meal. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of six (6) sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. All stairwells had evacuation chairs per regulation. Continued on 809-C... ...Continued from 809 The facility's smoke and carbon monoxide detectors and sprinkler system were last inspected on 3/5/2025. All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged on 10/9/2024. The facility conducts disaster drills quarterly. The last disaster drill was conducted on 2/28/2025. LPA conducted a sample file review of six (6) staff members. All staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for six (6) residents. Upon review, LPA observed residents to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to residents in care. LPA conducted a spot check of five (5) residents’ medications and observed all documentation and medications to be in order. During the tour, residents were observed interacting with staff in common spaces, resting in their private apartments, participating in various activities and mingling amongst each other. The Facility has a library and a beauty salon for the residents that operates several days a week. The facility provides an eclectic range of activities for it's residents. Jeanette Kinney’s Administrator Certification 7016943740 is current with an expiration date of 8/12/2026. LPA is requesting the following documents submitted to CCLD by 5/9/2025: LIC 500 Personnel Report LIC 308 Designation of Responsibility LIC 610E Emergency Disaster Plan Updated Liability Insurance No deficiencies cited during today's visit. Exit interview conducted. Copy of report and discussed and provided to ED Kinney. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 9, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

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... Unsubstantiated Continued from 9099... Documentation of shower refusals shows that witness (I1) was present during at least one of the shower refusals. On 7/21/24 resident received a shower by the Health and Wellness Director (HWD). HWD noticed scratches on R1’s back and torso. HWD questioned staff and witnesses I1 and I2 about the scratches. HWD discussed with I1 and I2 possibly changing laundry soaps and HWD took pictures to send to R1’s Primary Care Physician (PCP) to try and figure out what was going on with the scratches. HWD never heard back from the PCP or I1 about the cause of the scratches. One week after the discussion, R1 went to the hospital for a fall. During investigation, LPA reviewed charting progress notes and Incident reports submitted to CCL. On 7/30/24 R1 had a fall resulting in head injury and was admitted to the hospital. LPA reviewed hospital discharge papers. Per discharge papers, R1 was treated for a fall, head contusion, and dizziness, no mention of scabies in discharge papers. On 8/1/24 R1 returned to facility. According to charting progress notes, on 8/2/24 and 8/3/24 R1 mostly stayed in their room and R1’s head dressing was attended to by staff. On 8/4/24 R1 went back to the hospital due to staff noticing R1 speaking and acting in an altered state of consciousness. On 8/6/24 charting progress notes indicate facility LVN (S1) called hospital to inquire of R1’s status, S1’s charting progress note indicates R1 is being admitted for cellulitis. LPA unable to obtain discharge papers for hospital visit on 8/4/24. R1 never returned to the facility. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Complaint alleges due to staff neglect, resident sustained a pressure injury. Complainant states they observed a dime sized wound on R1’s back and on R1’s arm. During investigation, LPA reviewed charting progress notes and obtained photograph of R1’s arm, no picture of R1’s back was available. Per LPA observation, wound on arm does not appear to be a pressure wound as slough does not appear to be present, and no appearance of drainage or blisters observed. Per LPA review of charting progress notes, staff documented at least weekly observations, if not daily, of R1’s behavior and care needs. Charting progress notes do not reflect observation of pressure wounds. LPA review of 7/31/24 hospital discharge papers does not indicate any pressure wound observed or treated. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Administrator and a copy of this report was given.the 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 is done once a week. Continued on 9099C... Unsubstantiated Continued from 9099... Hairstylist services are available; she is an outside contractor and she makes her own schedule. Facility offers the activities and makes them available; residents can be encouraged to go, but it is up to the resident to sign up and participate. Care notes reveal resident attended happy hour on 9/22/2023 and 9/29/2023. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Complaint alleges Facility did not follow Admission Agreement. Complainant states that resident was charged for services that were already paid for as part of the costs outlined in their original admission agreement. During investigation, review of care notes reveal that between 9/2/2022 and 3/6/2023 facility held care conference 3 times with POA about the increased care needs of resident; 9/14/2023 care notes reveal resident was observed banging their head against the wall and trying to elope due to confusion and disorientation. HWD notified and POA notified; 9/27/2023 and 9/29/2023 resident tried to elope across the street due to cognitive decline and confusion; increased care needs once again communicated to POA. Investigative review of resident’s Admission Agreement does not support the allegation. Increased care needs can dictate a higher level of care needed and the facility can increase charges on such a basis. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Complaint alleges facility shared resident's confidential information with an unauthorized person. Complainant states that Health and Wellness Director (HWD) had shared multiple pieces of information about the resident with Individual 1 (I1) without the resident’s POA’s permission. During investigation, LPA reviewed the resident’s Uniform Statutory Form Power of Attorney and I1 is named as been granted all powers listed, one of which includes “personal and family maintenance.” So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on 9099C(2)... Continued from 9099C... Complaint alleges facility forced resident to participate in memory testing without consent. During investigation, LPA’s review of Brookdale of Windsor’s memory testing policy includes disclosure of The Brief Interview for Mental Status (BIMS), a screening tool that evaluates a resident’s cognitive functioning. The disclosure outlines the components of the screening, the policy detail, the conditions under which additional BIMS will be administered, a description of the BIMS scoring scale, and the actions that could be taken by the facility based on the BIMS score a resident receives. Per LPA interview with staff, this disclosure was provided to resident at time of admission and an initial BIMS was administered. LPA was provided with copy of disclosure during investigation. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Complaint alleges facility did not ensure that resident was adequately fed. During investigation LPA’s review of resident’s Care notes from 9/2022 to 10/2023 reveals that resident refused meals well over 70 times, often sleeping all day and refusing to leave her bed or room. Facility often left trays of food and tried encouraging resident in attempts to get them to eat. LPA’s review of resident’s privately paid caregiver notes also reveals that resident did not touch the food provided to her or refused food when offered or encouraged to eat. Per the facility, there was no communication with resident’s PCP pertaining to weight loss because in looking at their records of the resident’s weight, there was not significant weight loss to require contact to PCP. LPA review of weight loss records shows weights between 116.8 lbs to 129 lbs, taken between 1/21/2022 and 10/5/2023; first weight measurement was 126.2 lbs, last weight was measurement was 121.4 lbs. The lowest weight was measured at 116.8 lbs, taken 3 days after which the resident had returned to the facility from having been hospitalized. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on 9099C(3)... Continued from 9099C(2)... Complaint alleges Personal Rights. Complainant reports that the Health and Wellness Director (HWD) did not treat the resident with dignity and respect; that in in September of 2023 they grabbed the resident by the arm and frightened the resident. During investigation, LPA interviewed HWD, they indicated that no physical incident occurred between me and the resident in Sept 2023: "the resident was pleasant and was not a physical person. I was actually out of the community from Aug 1, 2023 to the first week of September 2023. When I returned, I was under absolute light duty, basically just in my office not really providing care to residents." During the complaint investigation, LPA interviewed three staff members. Three [3] out of three [3] staff reported that they have never observed any staff, including the HWD be inappropriate with a resident, be physically abusive, or treat them disrespectfully. During investigation, LPA did not observe any staff to be inappropriate with a resident, be physically abusive, or treat them disrespectfully. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Complaint alleges facility did not safeguard resident's personal items. Complainant states that a ring and necklace were missing from resident’s personal belongings. During investigation LPA observed resident’s care notes to address the necklace. Care notes state that on 2/18/2023 care notes report that while taking out resident’s laundry a necklace that might be of value was found in a green dress pocket, the resident then put it on and wore it. In LPA review of care notes and resident’s file, there is no mention of a missing ring or reports of missing items prior to resident’s permanently leaving the facility. LPA did not observe a completed a personal belonging inventory list in resident’s facility file. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on 9099C(4)... Continued from 9099C(3)... Complaint alleges facility did not seek medical attention for the resident in a timely manner. Complainant states that resident had a pulmonary embolism, but facility did not seek medical attention in a timely manner. However, complainant states in their complaint that the facility had indeed called EMS immediately after trying to reach the complainant unsuccessfully. During investigation, LPA reviewed resident’s care notes log. Care notes show that between 9/2/2022- 9/4/22 resident went to hospital and resident’s Power of Attorney (POA) reported to facility that she had a pulmonary embolism, it was discussed at that time the possible need for increased care and safety checks. On 10/23/2022 care notes report that resident was acting erratic; 12/30/2022 care notes report that resident was found wandering and confused; on 2/14/2023 the facility called POA to discuss resident’s increasing care needs. Care conference held by facility with POA on 2/27/2023 to discuss cognition issues and depression. POA was not in agreement with facility assessment of current level of care needs as well as evaluation of cognition issues. Facility agreed to give resident a couple of weeks to see if behaviors improve. On 3/2/2023, care notes report that resident was complaining of pain that was the same kind of pain as when the resident had the pulmonary embolism. POA was informed and reported they were out of town but would be sending someone to get resident. Resident left facility at 2:00pm; later the same day facility discussed with POA care needs of resident and perhaps changing medication to mitigate symptoms. On 3/6/2023 facility again spoke with POA about increased needs of resident pertaining to ADL’s as a result of cognitive function decline, not physical limitations. Facility conducted a Care Conference discussion on 3/9/2023 about resident’s increased care needs. Additionally, in mid 2023 resident had a biopsy on their right leg. Investigative review of resident’s care notes shows multiple entries for attending to the wound care that was needed. On 8/28/2023 when it was noticed that there may be an issue with the wound, POA was notified the same day, facility suggested resident be seen by doctor. In all instances of needing immediate medical attention, investigation findings are that the facility did seek medical attention immediately when the situation warranted as such. Therefore, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Aug 20, 2024 · control 21-AS-20240426155018

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Christi Coppo and Jacqueline Macias arrived unannounced to conduct a required Annual inspection and was greeted by Staff. Administrator Jeannette Kinney was not available, but LPAs contacted and Admin indicated Tina Worden, Health and Wellness Director (HWD) has signing permissions. HWD arrived later. Facility contact information was reviewed. At approximately 10:15am LPAs and HWD toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner. LPAs observed cereal bag not properly sealed; open and exposed. English muffins were not properly stored in the bag; open and exposed. Ice cream tubs were not covered but stored in a covered ice cream freezer. White granular substance was stored in a plastic container with plastic “cling” wrap but without proper lid. Avocados were stored inside the refrigerator without being placed in a Ziploc or plastic wrap. Jello cups were stored on a tray but open and exposed without plastic wrap covering the cups. Container underneath the garbage disposal/sink area had food waste. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 116.9 F in community bathroom downstairs, 117.1 F in room #30, 119.1 F in room #68, 117.2 F in room #40, which are all within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 10/30/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational as indicated per Fire Safety Supply's Inspection, Testing, and Maintenance Report dated 12/27/23. Facility’s last quarterly disaster drills were conducted on 5/2/2024. Continued on 809C... Continued from 809... At approximately 12:00pm LPAs conducted a review of 5 resident records. All required documentation present. At approximately 1:00pm LPAs conducted review of 5 staff records. S1, S2, S3, S4, and S5 have no 1st AId/CPR, Health Screen, or Training records on file (respective deficiencies cited, see 809Ds). At approximately 3:00pm LPAs accompanied Med Tech on afternoon med pass. LPAs observed Med Tech to live pour medications and medication cart remained locked when out of Med Tech sight. Medication is centrally stored in a locked cabinet. No deficiencies Jeannette Kinney Administrator Certificate 7016943740 expires 8/12/2024. All fees are current. LPA and HWD discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. On 2/26/2024 CCL received an Incident Report indicating a resident R1 eloped on 2/22/2024. At approximately 5:20pm it was discovered that R1 was not accounted for in the dining services area. Per review of the Resident's Physician's Report, resident not able to leave facility unless escorted by family. The facility initiated elopement protocol. At 7:10pm the Health and Wellness Director received a call from EMS indicating they had found R1 and transported them to the hospital for safety. R1 was checked at the ER for injury, infection, and R1 returned to the facility at 9:30pm. Per incident report facility implemented 1:1 caregiver with R1 for safety. Resident then moved to a different facility and no longer resides at facility. On 5/3/2024 CCL received an Incident Report indicating there was a medication error as pertains to resident R2 on 4/16/2024. At approximately 7:30pm on 4/16/24 staff on duty gave R2 a dose of Nitrofurantoin and one dose of Phenazophyridine in error. These two medications were received and entered under the wrong resident's profile. The error was discovered during the shift change. Nurse immediately reported the error. Continued on 809C(2)... Continued from 809C... Per Incident Report, resident did not have any adverse reaction or side effects from medication error. PCP notified by phone and responded that medical treatment was not necessary. R2 was placed on monitoring and increased safety checks for 72 hours. Per Incident Report, staff that made the error received formal counseling and training with Health and Wellness Director (HWD). Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with HWD. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with HWD and a copy of this report was giventhe state’s words, verbatim · CDSS document, May 30, 2024

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

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 Unsubstantiated Continued from LIC9099 The Department confirmed through review of doctor’s report that resident was seen by the doctor on 11/6/2023 and an ulcer was noted on the heel along with care instructions. The Department was unable to determine if staff observed a change of condition and failed to report it. Staff are not following resident's doctor's orders – Complaint alleges that after care instructions from the doctor were not followed resulting in a cellulitis infection. Review of doctor’s report dated 11/6/2023, stated that resident had a new ulcer that “should be inspected every 48 hours, cleaned, and dressed with a non-adherent dressing” adding that resident will be starting home health care. Review of facility’s Third-Party Collaboration Notes, stated that the home health agency provided wound care on 11/8/2023 and instructed facility to float heel and look for signs of infection. Progress notes indicated that dressing on wound was clean and intact on 11/9/2023 but on 11/10/2023, resident was sent to the hospital due to signs of infection. Witness interview indicates that resident was observed with both feet on the bed and that heels were not floated. Staff interviews indicate that they attempted to float resident’s heels, but resident frequently kicked the object being used to float the heels resulting in the heels no longer being floated. Review of progress note dated 11/9/2023 indicates that the foot board of resident’s bed was padded with a blanket to prevent injury. Pictures provided to Department show an increase in redness to heel from 11/8/2023 to 11/10/2023. Per staff interviews, resident has edema so swelling and redness is normal and increased redness was not observed. The Department was unable to determine if facility staff failed to follow doctor’s orders. Staff does not provide resident with dry linen – Complaint alleges that resident was observed with their foot with the wound sitting on a wet surface on their bed. Per witness interview, the sheet under the foot was “saturated” but it was not clear if the wet surface was discharge from the wound or if something was spilled. The Department was unable to determine how long the resident’s foot was on the wet surface and if it was observed by facility staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 21-AS-20231117090301

Type of visit: Case Management - Incident

At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Health and Wellness Director, Tina Worden. The purpose of today's visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). SOC-341 Report 1: CCL received an SOC-341 on 12/08/2023. Report stated possible suspicion of financial abuse. Facility found that Resident 1 (R1) was found to be missing $140 on 12/08/2023. R1's Responsible Party also reported to Facility that $1700 had been missing from R1's room approximately 3 months prior to report. SOC-341 Report 2: CCL received an SOC-341 on 01/02/2024. Report stated possible suspicion of financial abuse. It was reported that Resident 2 (R2) was missing money and other items from their room. Facility was informed by R2's Responsible Party on 12/28/2023, it was discovered that $580, bag of jewelry, and a blanket were missing from R2's room. Facility made all appropriate notifications per regulation. Facility has continued to communicate with Responsible Parties regarding theft. Facility intends on conducting a Town Hall meeting to address theft prevention measures. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Health and Wellness Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 15, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Jeanette Kinney. LPA is following up regarding a self-reported incident where a staff allegedly violated the personal rights of a resident in care. Per Administrator, they are conducting an internal investigation regarding the allegation but have not yet come to a determination. The involved staff is currently on leave pending the outcome of the investigation. Facility has cross-reported incident per mandatory reporting requirements. LPA conducted interviews and will obtain additional information. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Nov 17, 2023

Type of visit: Case Management - Incident

Licensing Program Analysts Bertozzi and Coppo arrived unannounced to complete a case management inspection. LPAs met with Executive Director Jeannette Kinney. LPAs requested and reviewed resident files for two residents. LPAs are following up on self-reported incident report for R1. Per incident report resident was transported to the hospital following a positive COVID diagnosis and because of additional health concerns. LPAs reviewed resident's care plan which indicated that the facility's health concerns were documented in R1's care plan. Additionally, the resident was under the care of a third party home health care agency. Per special incident report R2 recently fell on bathroom floor, resulting in a head laceration and fracture. Incident report indicates resident was confused and vomiting. R2 was sent to the hospital 9/11/2023 and later passed away. Resident did not need one to one supervision per their care plan.the state’s words, verbatim · CDSS document, Oct 3, 2023