496802025-2-15-2024-21-AS-BMOS-D2TPDV-20240226101409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802025
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:24:17 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231117090301

FACILITY NAME:	BROOKDALE WINDSOR		FACILITY NUMBER:	496802025
ADMINISTRATOR:	KINNEY, JEANNETTE		FACILITY TYPE:	740
ADDRESS:	907 ADELE DR		TELEPHONE:	(707) 837-8785
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	80	CENSUS: 55	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Health and Wellness Director, Tina Worden		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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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.

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231117090301

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE WINDSOR	FACILITY NUMBER: 496802025
	VISIT DATE: 02/15/2024

NARRATIVE

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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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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