BROOKDALE WINDSOR

Official classification

Type A

Official code

87468.2(a)(20)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jul 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87469(c)(3)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jun 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

§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.

Official 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.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and HWD observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have current First Aid/CPR, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2024 Plan of Correction Facility to submit plan to have S1, S2, S3, S4, and S5 obtain First Aid/CPR certification by 5/31/2024. Certification to be completed for all identified staff no later than 6/13/2024.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on incident report received on 5/3/2024, the licensee did not comply with the section cited above in that R2 received medication not prescribed to them, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2024 Plan of Correction Facility to provide CCL with training log showing training conducted with staff on medication management as indicated on Incident Report by Plan of Correction due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and HWD observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have Heath Screens, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Facility to submit pictures of completed Health Screens for S1, S2, S3, S4, and S5 plan of correction due date.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Deficient Practice Statement Based on on Incident Report received on 2/26/2024, the licensee did not comply with the section cited above in that R1 had an elopement, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Facility to train staff on elopement procedures and preventative measures, and submit training log to CCL by POC date. Training log to include name of trainer, name of course, staff attendees, and hours completed.

Official classification

Type B

Official code

87411(c)(6)

Regulation authority

CCR

What the official deficiency says

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have Training records available, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Facility to submit pictures of completed training logs for S1, S2, S3, S4, and S5 by plan of correction due date. Training logs to contain name of trainer, name of course, duration of course in hours, dated completed and employee attendee.