496802025-8-20-2024-21-AS-VBEI-D8ESD9-20240823134644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802025
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:25:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/26/2024 and conducted by Evaluator Christi Coppo

COMPLAINT CONTROL NUMBER: 21-AS-20240426155018

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: 59	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Jeanette Kinney, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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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

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 21-AS-20240426155018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE WINDSOR	FACILITY NUMBER: 496802025
	VISIT DATE: 08/20/2024

NARRATIVE

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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)...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20240426155018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE WINDSOR	FACILITY NUMBER: 496802025
	VISIT DATE: 08/20/2024

NARRATIVE

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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)...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20240426155018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE WINDSOR	FACILITY NUMBER: 496802025
	VISIT DATE: 08/20/2024

NARRATIVE

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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)...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20240426155018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE WINDSOR	FACILITY NUMBER: 496802025
	VISIT DATE: 08/20/2024

NARRATIVE

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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.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

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