Compass Park

In the surveyor’s words

From the most serious findings on record at Compass Park, in the surveyor’s own words.

• Actual harm, isolatedF760May 12, 2022

  Based on interview and record review, the facility failed to ensure a resident was free from significant medication errors for 1 of 3 residents reviewed. This resulted in a resident not progressing in therapy. (Resident B) Finding includes: During an interview on 5/12/22 at 9:20 a.m., the Director of Nursing indicated when a new admission arrived, the nurse should enter the orders into the electronic medical record and the physician was able to verify and approve those orders through the electronic medical record. The nurse should clarify any orders they question. The Director of Nursing indicated Resident B's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF812Nov 8, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 2 of 3 kitchen observations. Staff hair was not covered while in the kitchen. (Kitchen Staff 2, Kitchen Staff 3, Kitchen Staff 4, Cook 5, Kitchen Staff 6) Findings include: 1. During the initial kitchen observation on 11/1/23 from 11:00 a.m. to 11:30 a.m., the following was observed: - Kitchen Staff 2 was observed walking throughout the kitchen area and preparing the noon meal trays near the steam table where the noon meal was being held. Kitchen Staff 2 was observed to have multiple loose hairs, approximately 10 inches in length, in front of both ears. […]

• No harm, potential for more than minimal, isolatedF583Aug 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure privacy was provided during personal care for 1 of 7 residents observed for personal care. (Resident 137)Finding includes:On 8/4/25 at 11:50 a.m., the clinical record for Resident 137 was reviewed. The diagnosis included, but was not limited to, idiopathic pulmonary fibrosis (a chronic progressive lung disease that causes irreversible scarring in the lungs).The clinical record indicated on 10/18/24 Resident 137 elected to receive hospice care.On 8/4/25 at 11:33 a.m. observed Resident 137's door half open. Resident 137 was receiving incontinent care. […]

• No harm, potential for more than minimal, isolatedF623Sep 20, 2024

  Based on interview and record review, the facility failed to ensure that written notification was provided to the resident, the resident's representative, and to the Office of the State Long-Term Care Ombudsman for 3 of 5 residents reviewed for written transfer and discharge notification. (Resident 140, Resident 1, Resident 123) Findings include: 1. On 9/18/24 at 2:12 p.m., Resident 140's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure, and orthostatic hypotension (form of low blood pressure that happens when standing after sitting or lying down). Resident 140's face sheet had identified a family member as the emergency contact person. […]

• No harm, potential for more than minimal, isolatedF625Sep 20, 2024

  Based on interview and record review, the facility failed to ensure a written bed hold notification was provided to the resident and to the resident's representative for 3 of 5 residents reviewed for bed hold notifications. (Resident 1, Resident 123, and Resident 140) Findings include: 1. On 9/16/24 at 10:55 a.m., Resident 1's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, acute and chronic respiratory failure, and heart failure. Resident 1 had identified a family member as the resident's guardian and emergency contact person. The Quarterly Minimum Data Set (MDS) assessment, dated 7/24/24, indicated Resident 1 was moderately cognitively impaired. […]