complaint·July 30, 2025

...Continued from 9099 During investigation, LPA reviewed Chart Notes. The first Chart Note dated 4/10/2025, 11:30 AM stated that resident R1 was sent to Sutter Hospital Santa Rosa for “dangerous high glucose level”. The charting notes further indicated that R1 was showing signs of anxiety and stress. The 911 call was initiated by R1’s third party Behavior Specialist/BSN (BSN1). The next “Alert Charting Note” text dated 4/10/2025 22:58 states, “Resident called about ten 10 times, requesting to come back to the community. According to the ED, resident isn’t allowed to come back at this time, until they (R1) receive proper treatment, prior to returning”. LPA interviewed Executive Director (ED) Jeannette Kinney at 2:16 PM on 4/22/2025. When asked, “was R1 denied a return to the facility?”, ED Kinney responded, “Yes, we couldn’t control R1’s behaviors.” Based on interviews and review of care plan, R1 transferred from another Brookdale community and their behaviors were known and documented upon admission to Brookdale Windsor. Based on LPA’s interview, record review and express admission the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, 87468.2(a)(20) are being cited on the attached 9099D. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-9099D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Kinney. Signature on form confirms receipt of documents