Inspection Reports for Brookdale Windsor

The visit was an office meeting held to address areas of concern identified by the Department, specifically regarding personal rights/wrongful evictions and seeking timely medical care for residents.

The report indicates that deficiencies were cited related to the facility not seeking timely medical care for a resident, and the issuance of a civil penalty is under review based on these violations.

Deficiencies were cited on Complaint Control Number 21-AS-20250415140750. The issuance of a civil penalty is under review based on the complaint regarding timely medical care.

The inspection was an unannounced complaint investigation triggered by an allegation received on 2025-04-15 regarding an unlawful eviction of a resident who was denied the ability to return to the facility after a hospital visit.

The investigation substantiated that the facility did not comply with regulations by denying resident R1 the ability to return after a hospital emergency room visit without providing the required eviction notice or approval. The resident's behaviors were known and documented upon admission, and the denial posed an immediate health, safety, or personal rights risk.

The complaint alleged unlawful eviction of resident R1 who was sent to the hospital on 2025-04-11 and denied return to the facility without a 30-day eviction notice or approval for a 3-day notice. The allegation was substantiated based on interviews, record review, and evidence.

An unannounced complaint investigation was conducted based on allegations received on 2025-02-05 regarding failure to seek timely medical care, inadequate room cleanliness, lack of explanation of services, and failure to provide itemization of charges to residents' responsible persons.

The investigation substantiated all allegations: the facility delayed sending a resident with a head injury to the hospital, failed to properly clean a resident's room, and did not provide timely written notification or itemization of charges related to a change in level of care to the responsible party. Deficiencies were cited under California Code of Regulations Title 22 and Health and Safety Code.

The complaint investigation was substantiated. Allegations included failure to seek timely medical care for a resident who fell and sustained a head injury, failure to maintain cleanliness of a resident's room, and failure to provide explanation and itemization of charges related to a new level of care to the resident's responsible party. The facility delayed sending the resident to the hospital for nearly two hours and waited for hospice to make the decision. The responsible party was not timely notified of rate increases as required.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not dispense medications as prescribed.

The investigation found a delay in a resident receiving new medications prescribed at discharge due to unclear adherence to facility protocol and absence of the Health and Wellness Director. However, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.

The complaint alleged that medications were not dispensed as prescribed to a resident discharged to the facility. The investigation reviewed staffing schedules, medication administration records, and agreements with the pharmacy. The allegation was unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced 1-Year Required annual inspection of the Brookdale Windsor Assisted Living facility to assess compliance with licensing requirements.

The facility was found to be clean, orderly, and compliant with regulations including fire safety, emergency preparedness, staff training, and resident care documentation. No deficiencies were cited during the visit.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-08-12 regarding staff not ensuring a resident was free of scabies and staff neglect resulting in a resident sustaining a pressure injury.

The investigation found insufficient evidence to substantiate the allegations. The resident refused most scheduled showers, limiting staff's ability to observe skin for scabies. Hospital discharge papers did not mention scabies. The alleged pressure injury was not observed to be a pressure wound, and charting notes did not reflect pressure wounds. Therefore, both allegations were unsubstantiated.

The complaint was unsubstantiated. Allegations included staff failing to ensure a resident was free of scabies and neglect causing a pressure injury. Investigations included review of medical records, incident reports, hospital discharge papers, and observations. No preponderance of evidence was found to prove the alleged violations.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-04-26 regarding the facility's care and operations.

The investigation found no preponderance of evidence to substantiate any of the nine allegations, including issues related to daily activities, admission agreement compliance, confidentiality breaches, forced memory testing, adequate feeding, personal rights, safeguarding personal items, and timely medical attention. The report concluded all allegations as unsubstantiated and cited no deficiencies.

The complaint investigation addressed nine allegations including failure to provide daily activities, not following the admission agreement, sharing confidential information without authorization, forcing memory testing without consent, inadequate feeding, violation of personal rights, failure to safeguard personal items, and not seeking timely medical attention. All allegations were found unsubstantiated after review of care notes, interviews, and policy documents.

The inspection was a required unannounced annual inspection conducted to evaluate compliance with licensing regulations and facility standards.

The facility was generally clean and well-maintained with proper food storage issues noted. Several deficiencies were cited related to staff training, health screenings, and medication administration errors. An elopement incident was reported and addressed with corrective actions.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-17 regarding resident care issues including development of a pressure injury, failure to follow doctor's orders, and failure to provide dry linen.

The investigation found insufficient evidence to substantiate the allegations. The department was unable to determine if staff observed and reported the pressure injury, followed doctor's wound care orders, or provided dry linen as alleged. No deficiencies were cited during the visit.

The complaint alleged that a resident developed a pressure injury that was not observed or reported by staff, that staff failed to follow doctor's orders for wound care resulting in cellulitis infection, and that staff did not provide dry linen causing the resident's foot to be on a wet surface. The investigation was unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced Case Management - Incident inspection to follow up on self-reported incidents of possible financial abuse involving residents.

The facility reported two incidents of suspected financial abuse involving missing money and items from residents' rooms. The facility made all appropriate notifications and communicated with responsible parties. No deficiencies were cited during the visit.

The visit followed up on two SOC-341 reports received on 12/08/2023 and 01/02/2024 regarding suspected financial abuse involving missing money and items from Resident 1 and Resident 2. The facility found $140 missing from Resident 1 on 12/08/2023 and $1700 missing approximately 3 months prior. Resident 2 was reported missing $580, a bag of jewelry, and a blanket as of 12/28/2023. The facility communicated with responsible parties and planned a Town Hall meeting to address theft prevention.

The inspection was conducted as a Case Management follow-up regarding a self-reported incident where a staff allegedly violated the personal rights of a resident in care.

The Licensing Program Analyst conducted interviews and is obtaining additional information. The facility is conducting an internal investigation and the involved staff is on leave. No deficiencies were cited during this inspection.

The visit was complaint-related due to a self-reported incident alleging violation of a resident's personal rights. The facility is investigating internally and has cross-reported the incident as required. The Licensing Program Analyst is following up and gathering more information.

The inspection was an unannounced case management visit to follow up on self-reported incidents involving two residents, including a positive COVID diagnosis and a fall resulting in injury and death.

The inspection reviewed resident files and care plans related to the incidents. One resident was hospitalized due to COVID and other health concerns, and another resident suffered a fall causing a head laceration and fracture, later passing away. The care plans were found to document relevant health concerns and supervision needs.

The visit was triggered by self-reported incidents involving two residents: one hospitalized after a positive COVID diagnosis and another who fell, suffered injuries, and later died. The resident did not require one-to-one supervision per their care plan.

The inspection was an unannounced Case Management visit conducted to review reports regarding a resident who was recently discharged from hospice services and had an incident involving a fall.

No deficiencies were cited during this inspection. The resident was found on the floor by staff, denied pain initially, later complained of pain and was transported to the hospital where they passed away three days later. The resident did not require 1:1 supervision per file review.

An unannounced annual required inspection was conducted to evaluate compliance with licensing regulations.

The facility was found to be in compliance with regulations, with no deficiencies cited. Observations included appropriate water temperatures, secured medications, proper storage of food and cleaning supplies, and up-to-date fire safety equipment and drills.

The inspection was an unannounced Case Management visit to follow up on three incidents involving residents, including two incidents between residents R1 and R2 and a third incident involving resident R3's injury during a transfer.

The inspection found no deficiencies. The incidents involved resident interactions and an injury requiring hospital transport, with appropriate follow-up actions taken by the facility and consultation with responsible parties.

The visit was complaint-related, following up on three incidents: two involving residents R1 and R2 with behavioral issues and one involving resident R3 who sustained a leg break during a transfer. The complaint was investigated with review of care plans, staff training, and physician reports. No deficiencies were cited.

Unannounced complaint investigation visit conducted in response to allegations including questionable deaths, failure to seek timely medical attention for residents, and failure to report incidents involving residents.

The investigation found the complaint to be unfounded after interviews, observations, and document reviews. Evidence did not support the alleged incident of residents ingesting chemicals, and staff denied the occurrence. Police logs showed no response to such an incident, and resident death reports did not indicate chemical ingestion.

Complaint alleged multiple residents died after ingesting chemicals instead of juice, staff delayed calling emergency services for 1.5 hours, and incidents were not reported to licensing. The complaint was found to be unfounded.

The inspection was an unannounced Annual Required inspection focused on the Infection Control procedures and practices of the facility.

The facility maintained infection control measures including hand sanitizer stations, mask requirements for staff, and signage for residents. The facility had no deficiencies cited during this inspection and maintained adequate supplies of PPE and medication. Discussions included visitation policies, emergency disaster plans, and infection control plans.

The inspection was an unannounced Case Management visit to follow up on two self-reported incidents involving residents who had un-witnessed falls resulting in injuries.

No deficiencies were cited during this inspection. Both residents involved in the incidents did not require one-to-one assistance and were receiving appropriate follow-up care.

The inspection was an unannounced Annual Required inspection focused on the Infection Control procedures and practices of the facility.

The facility demonstrated compliance with infection control practices including use of hand sanitizer, mask wearing by staff, social distancing in dining and common areas, PPE training and fit testing, and approved Covid Mitigation Plan. No deficiencies were cited during this inspection.

An unannounced complaint investigation was conducted in response to an allegation that the facility was in disrepair.

The investigation found the complaint to be unfounded, with no evidence of disrepair or issues. The city water department inspected the water supply and found no problems. No citations were issued.

The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging the facility failed to readmit a resident in a timely manner upon discharge from the hospital and alleged insufficient staffing.

The complaint that the facility failed to readmit a resident in a timely manner was substantiated, with evidence showing Covid positive residents were transferred to skilled nursing or designated Covid facilities regardless of symptoms. The allegation of insufficient staffing was unsubstantiated and dismissed. No deficiencies were cited for staffing.

The complaint was substantiated regarding failure to readmit a resident timely after hospital discharge. The allegation of insufficient staffing was unsubstantiated and dismissed.