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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001756
Report Date: 11/05/2020
Date Signed: 11/05/2020 12:25:17 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2020 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20200606133857
FACILITY NAME:COMPASS ROSEFACILITY NUMBER:
045001756
ADMINISTRATOR:FREUDENDAHL, TRACYFACILITY TYPE:
740
ADDRESS:2750 SIERRA SUNRISE TERRACETELEPHONE:
(530) 774-2705
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:48CENSUS: 19DATE:
11/05/2020
ANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Cliff KeeneTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Lack of supervision
Personal Rights
administered medication in unsafe manner
INVESTIGATION FINDINGS:
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On 11/5/2020 at 1030 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility and met with Cliff Keen, Administrator. The purpose of the visit to is deliver the following complaint findings. Precautionary measures were taken regarding COVID 19. LPA arrived donned in PPE to include N95, Gown and Gloves. LPA and administrator remained outside the facility.

On 06/06/2020, California Department of Social Services Community Care Licensing received a complaint alleging Compass Rose failed to provide care and supervision to a resident (R1) and due to the lack of care and supervision by facility staff, R1 was hospitalized and sustained injuries. It was also alleged the facility administered medication to R1 in an unsafe manner. It is alleged the facility did not protect the personal rights of a resident in care. These allegations are substantiated. The findings are as follows:

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 25-AS-20200606133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
VISIT DATE: 11/05/2020
NARRATIVE
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This department has investigated the complaint and following are the findings: Facility staff failed to provide appropriate care and supervision to R1. The facility staff did not follow their own Fall Response Procedures in that: a Morse Fall Scale (MFS) assessment was not able to be shown to have been completed following related falls: R1’s service/care plan was never updated; although interventions were implemented (wheelchair and bed rails), seat and bed alarms were never installed as prescribed by R1’s physician: R1 sustained additional falls and the facility’s Resident Services Director (RSD) also a Licensed Vocational Nurse (LVN) never requested additional interventions.

Multiple staff were interviewed and reported that they were never notified of any required changes to R1’s service/care plan. Multiple staff interviewed reported they observed and reported to the RSD a change in R1’s care needs and advised the RSD that R1 may require 1:1 care. RSD admitted that seat or bed alarms were never installed. Interviews with staff and facility residents revealed that some residents have alarm pendants that they wear to alert staff. An alarm pendant was never offered as a possible intervention for R1. R1 did not have a signal system in R1’s living unit. The closest available pull cord to summon assistance was in the attached bathroom. Staff indicated R1 would be unable to summon assistance due to the location of the signal system.

Substantial documentary evidenced was obtained and reviewed revealing that the facility was notified and aware that R1 was high fall risk following an incident on 4/24/2020, when Koch “slid” out of bed, sustaining a “contusion of the forehead, initial encounter” and a “closed fracture of distal end of left radius.” On 4/27/20, a documented Physician Communication log between the facility and R1’s physician was obtained that stated per the physician, “Patient to be strictly monitored as a high-risk fall. Medication had to be ordered for patient’s safety. Seat sensor and bed sensor to be ordered for routine use for patient’s protection. R1 is a high risk for falls.” Medical records document a TeleMED Zoom visit held on 4/27/20 where physician “discussed with the caregiver (identified as RSD) and R1’s daughter” that she was concerned about sedation and risk of falls and the “importance of monitoring and preventing additional injury to the patient. R1 is at high risk of fall and it is deemed medically necessary for her to have a hospital bed with railing. Additionally, R1 is to have alarm pads for the bed, was well as for seating to prevent additional injury.” Physician was “emphatic about concerns for R1’s Safety.”

Cont'd on LIC 9099-C
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 25-AS-20200606133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
VISIT DATE: 11/05/2020
NARRATIVE
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Approximately two weeks later a wheelchair was provided, and bed rails were installed. Seat and bed alarms were never installed, as prescribed by R1’s physician on 4/24/20.

Following multiple notifications that R1 was a high fall risk, the physicians order for seat and bed alarms were never fulfilled. R1 sustained documented falls (both witnessed and unwitnessed) on 05/03/2020, 05/05/2020 (required medical treatment for bruised hip), 05/07/2020 (two falls), 05/12/2020 (required medical treatment on 5/13/2020 for multiple fractured ribs).

During the investigation, it was determined R1 experienced two additional falls on 07/09/2020, the second of which resulted in transportation to the hospital after R struck her head. Staff stated R1 was seen using the walker in an unsafe manner on 07/09/2020, prior to the fall and admitted that R1 had not been using R1’s wheelchair. On 07/10/2020 this department conducted a facility visit and observed R1 sitting, unattended, in the dining room of the facility, without a walker or wheelchair nearby. Staff were unsure where R1’s walker was and assumed, R1 left it in the living room. R1’s wheelchair was located in R1’s bedroom.

Medication was administered to R1 in an unsafe manner: It was alleged by facility staff and R1’s physician that R1 received a double dose of medication on 4/27/2020 between the hours of 0600-1430 hours. R1 was hospitalized after being found unresponsive in her wheelchair on 4/28/2020 at approximately 1115 hours. Corresponding medical records were reviewed and stated, “increased as needed medications for her behavioral disturbance may have been contributor to her likelihood of falling,” However, it was also documented that R1 had a previously documented related medical condition. ER doctor revealed to family “the change in her meds may have caused the passing out because of a low heart rate.”

Facility RSD admitted to administering to R1’s medication on 04/27/2020 at 1131 hours in addition to a PRN dosage given at 0522 hours and the routine dosage given at 0900 hours but denied that the dosage was med error. A review of records revealed an “Order note” from the physician stating “My patient cannot determine his/her need for prescription medication but can clearly communicate his/her symptoms indicating a need for a PRN Medication. Must contact doctor before a PRN medication is given to patient.” Interviews revealed staff failed to follow this order to include the RSD and were administering the medication without first contacting the physician.

Cont'd on LIC 9099-C
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 25-AS-20200606133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
VISIT DATE: 11/05/2020
NARRATIVE
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Based on interviews and review of records, the Licensee failed to provide care, supervision and safe accommodations necessary to meet one of one resident's needs resulting in need for medical attention. The allegation is substantiated.

Civil penalties assessed today in the amount of $500.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 25-AS-20200606133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited
HSC
1560.269(a)(6)
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Enumerated rights; severability. 1569.269(a)(6). To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The requirement is not met as evidenced by:
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Licensee will will provide a plan by to address deficiency by COB on 11/5/20
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Based on interviews and documents obtained the licensee failed to ensure there was sufficient staff to meet the resident’s needs, which resulted in R1 being hospitalized. This poses an immediate health and safety risk to residents in care.
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Type A
11/06/2020
Section Cited
CCR
87411(a)
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Personnel Requirements 87411(a)-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs
This requirement is not met as evidence by: Based on interviews and documents obtained the licensee failed to have enough
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Licensee will will provide a plan by to address deficiency by COB on 11/5/20
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staff on duty to ensure one of one resident’s needs were met. R1 had unsupervised falls, had become unresponsive while in her wheelchair and hospitalized with a fractured distal end of left radius, fractured ribs. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 25-AS-20200606133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited
CCR
87705(c)(5)(A)
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87705 (c)(5)(A) Care of Persons with Dementia- When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidence by: Based on interviews and documents obtained
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Licensee agrees to communicaate with physician for a new 602 and medication list. Facility will create and impliment new care plan to meet residents needs. Plan will be provided to CCL by COB on 11/6/20
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the licensee failed to: Update R1’s care plan. R1 had a dementia, was hospitalized, diagnosed with injuries and the licensee failed to make corresponding changes to the care and supervision of 1 of 1 residents which resulted in a lack of supervision to meet R1’s needs. This poses and immediate health and safety risk to residents in care.
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Type A
11/06/2020
Section Cited
CCR
87303(i)(1)(A)
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87303(i)(1)(A) Maintenance and Operation-Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 … shall have a signal system which shall: Operate from each resident's living unit. This requirement is not met as evidence by: Based on interviews and documents obtained the licensee failed to
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Licensee agrees to assess residents for need of a pendant to summon for help. Plan will be provided to CCL by COB 11/6/20
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Provide 1 of 1 resident with an accessible signal system. R1 had documented falls to include in R1’s room however a signal system to summon help was never offered. This poses an immediate health and safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 25-AS-20200606133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited
CCR
87465(a)(2)
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87465(a)(2) Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed. The plan shall encourage routine medical care, provide for assistance in obtaining such care, by compliane: The licensee shall provide assistance in meeting necessary medical needs. This requirement is not met
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Licensee agrees to follow an fulfill physicians orders. Licensee will develop a plan to ensure these requirements are met and will submit to CCL no later than COB 11/6/20
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as evidence by: Based on interviews and documents obtained the licensee failed to Meet the necessary medical needs of 1 of 1 resident by not providing seat and bed alarms as prescribed by R1’s physician. The order was never fulfilled by the facility although R1 had repeated falls. This poses an immediate health and safety risk to residents in care.
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Type A
11/06/2020
Section Cited
CCR
87465(d)(1)
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87465(d)(1) Incidental Medical and Dental Care- If the resident is unable to determine own need for a prescription PRN medication, is unable to communicate symptoms, staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction This requirement is not met as evidence by:
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Licensee agrees to develop a plan and will conduct a retraining of PRN administration. Plan will be submitted to CCL no later than 11/6/20.
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 Based on interviews and documents obtained the licensee failed to: Staff failed to contact one of one resident’s physician prior to each dose of the prescribed PRN as requested by physician which resulted in falls and hospitilization. This poses an immediate health and safety risk to residents in care.
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Civil Penalties assessed in the amount of $500
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7