Compass Healthcare and Rehab Hawfields, Inc.

In the surveyor’s words

From the most serious findings on record at Compass Healthcare and Rehab Hawfields, Inc., in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 23, 2021

  Based on staff interviews, Nurse Practitioner (NP) and Medical Director telephone interviews, and facility and hospital record reviews, the facility neglected to provide medication treatment as ordered by the provider and to monitor a resident ' s bowel movements to prevent adverse consequences for 1 of 1 resident (Resident #1) reviewed for constipation. The resident was discharged to a hospital on [DATE] where she was determined to have a massive fecal impaction. The resident expired on [DATE] at 12:28 PM. Immediate Jeopardy began on [DATE] when the facility failed to administer daily scheduled [MEDICATION(S)] medication and transcribed the order into the facility's computer system as an as needed medication on three separate occasions ([DATE], [DATE] and [DATE]). […]

• No harm, potential for more than minimal, widespreadF880Dec 16, 2021

  Based on observations, staff interviews, record review, Center for Disease Control (CDC) guidelines for the use of Personal Protective Equipment (PPE), and the CDC COVID-19 Data Tracker for Alamance county's level of community transmission, all facility staff failed to wear eye protection during resident encounters. This failure occurred during a COVID-19 pandemic. In addition, the facility failed to follow infection control standards of practice by placing an indwelling urinary catheter bag on the floor for 1 of 2 residents reviewed for urinary catheters (Resident #38). The findings included: 1. […]

• No harm, potential for more than minimal, patternF812Oct 10, 2024

  Based on observations, and staff interviews, the facility failed to store food in the walk-in freezer not open to air and without freezer burn. The facility failed to discard foods past their use-by date, failed to label and date food placed in the nourishment refrigerator in 1 of 2 nourishment refrigerator/freezers reviewed for food storage (E/F hallway). The facility also failed to hold cold foods in a safe temperature range during tray line observation. These practices had the potential to affect food being served to the residents. Findings included: An observation of the walk-in freezer on [DATE] from at 9:30 AM to 9:45 AM revealed the following were located on shelves below the compressor: 1 a. An opened brown cardboard box labeled Chicken -10 lbs. that had ice on top of the box. […]

• No harm, potential for more than minimal, patternF585Jul 28, 2023

  Based on record review, Responsible Party and staff interviews, the facility failed to provide a written grievance summary for 1 of 1 sampled resident (Residents #8) reviewed for grievances. This practice occurred for 6 grievances filed on behalf of Resident #8. Findings include: Resident #8 was readmitted to the facility on [DATE]. Review of the Grievance Policy (revised dated July 2023) read in part The resident or person filling the grievance and/or complaint on behalf of the resident will be informed (verbally and in writing) of the findings of the investigation and the action that will be taken to correct any identified problems. A written summary of the investigation will also be provided to the resident and a copy will be filed. […]

• No harm, potential for more than minimal, patternF812Jul 28, 2023

  Based on observations, and staff interviews the facility failed to maintain the walk-in refrigerator floor and racks in clean condition, label foods and discard foods that were spoiled. The facility failed to maintain the double stack oven clean and without grease build up. The facility failed maintain food in the walk-in freezer without freezer burn. The facility also failed to hold hot food (equal to or greater than 135 degrees Fahrenheit (F) on the steam table during tray line observation. The facility failed to ensure a male dietary staff had all facial hair contained in a face covering. These practices had the potential to affect food being served to residents. Findings included: 1. […]