496802025-11-1-2024-21-AS-VBEI-DB9VMP-20241122153352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802025
Report Date: 11/01/2024
Date Signed: 11/01/2024 11:07:22 AM

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
08/12/2024 and conducted by Evaluator Christi Coppo

COMPLAINT CONTROL NUMBER: 21-AS-20240812081037

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:	DATE:	11/01/2024
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Jeannette Kinney, Administrator		TIME COMPLETED:	11:22 AM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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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

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: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

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-20240812081037

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: 11/01/2024

NARRATIVE

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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.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC9099 (FAS) - (06/04)

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