Inspection visit

complaintMay 30, 2025

BROOKDALE WINDSORLicense 496802025

Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

Continued from 9099... procedure when processing a medication change or new medication is to first obtain signed doctor’s orders before faxing to Consonus, whether or not HWD is present at facility. LPA also reviewed medication list and MAR for R1. LPA reviewed start dates of medications identified on discharge papers to be administered daily. List shows medications ordered on 2/20/25 but not given until 2/21/25 or 2/23/25 for Atorvastatin and Salon Pas. However, during investigation, LPA was provided copies of Brookdale's Pharmacy Service Agreement and the Consonus Pharmacy Customer Agreement signed by R1’s responsible party. Noted on the Consonus Pharmacy Customer Agreement is a handwritten addition indicating that Brookdale would only use Consonus for R1 in the cases of over-the-counter medication or urgent/emergency medications. Admin clarified with LPA that even in the cases of using Consonus for urgent medications, Brookdale must still provide the family with an opportunity to provide Brookdale the medication even though they signed the Consonus Pharmacy Customer Agreement. Admin advised Brookdale still must wait the two [2] days indicated in the Pharmacy Service Agreement, because some people don’t have a co-pay through their own pharmacy such as the V.A. and/or Kaiser, but through Consensus they have to pay a shared cost. Per LPA record review and interview, there was delay in R1 receiving the new medications prescribed at discharge; however, it is unclear if the facility was following their written protocol, allowing the responsible party to obtain the prescription prior to using Consonus or if there was a delay due to the absence of the HWD. 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. Note: LPA clarified protocols with facility to ensure there are not unnecessary delays in the future with residents’ medications being administered timely. Exit interview conducted with Administrator and a copy of this report given.

Citations

3 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

1569.657(a)Type B
§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.
87303(a)Type B
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.
87469(c)(3)Type A
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.
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FAQ · About this visit

Common questions about this visit

What happened during the May 30, 2025 inspection of BROOKDALE WINDSOR?

This was a complaint inspection of BROOKDALE WINDSOR on May 30, 2025. The inspection found no deficiencies and no citations were issued.

Were any citations issued to BROOKDALE WINDSOR on May 30, 2025?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·May 30, 2025