Compass Post Acute Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Apr 10, 2025

  Based on observation, interview, and policy review, the facility failed to ensure three of three observed employes (Cook1, Cook2, and Cook3) performed handwashing after they removed gloves prior to putting on a new pair. Cooks 1 and 3 touched foods with their gloved hands after touching other surfaces which put the food at risk of being contaminated. Findings include: Review of the facility's 2020 Guideline and Procedure policy indicated, All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2024

  Based on observations, interviews, and review of facility policy, the facility failed to ensure foods that were stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date. This had the potential to affect all residents who received meal trays from the kitchen. Findings include: Review of the facility's undated policy titled, Food Storage (Dry, Refrigerated, and Frozen) revealed, General storage guidelines to be followed: a. all food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded, 2. Aprons, guideline: Aprons shall be worn when preparing or serving food, Procedure: 1. […]

• No harm, potential for more than minimal, isolatedF657Apr 10, 2025

  51678 Based on record reviews, and interviews, the facility failed to ensure five of 22 sample residents (Resident (R)9, R52, R3, R16, and R34) were provided with the opportunity to attend their care conferences to express their concerns and needs. This failure has resulted in care conference's being completed without residents and/or representative's input and attendance. Findings include: 1. Review of R9's Admission Record, found in the resident's electronic medical record (EMR) under the Census tab revealed the facility admitted the resident on 01/22/24. […]

• No harm, potential for more than minimal, isolatedF690Jan 8, 2021

  Based on observation, interview, and review of the facility policy titled, Catheter Care, Indwelling, the facility failed to ensure proper catheter care for Resident # 11, for 1 of 3 residents reviewed with an indwelling catheter. The findings included: An observation on 1/7/2021 at approximately 10:30 AM of indwelling foley catheter care for Resident #11 revealed Registered Nurse (RN) #1 performing catheter care as follows: RN #1 washed his/her hands and applied clean gloves. He/she then proceeded to close the door of the resident's room, pull the privacy curtain, and using the bed remote control he/she raised the bed. Then using the same gloved hands put the feeding pump on hold, and took the remote control for the bed again and lowered the head of the bed. […]

• No harm, potential for more than minimal, isolatedF880Jan 8, 2021

  Based on observation, interview and review of the facility policy titled, Catheter Care, Indwelling, the facility failed to follow a procedure to decrease the risk of infection for Resident #11 during foley catheter care, 1 of 3 reviewed for indwelling catheters. The findings included: An observation on 1/7/2021 at approximately 10:30 AM of indwelling foley catheter care for Resident #11 revealed Registered Nurse (RN) #1 performing catheter care as follows: RN #1 washed his/her hands and applied clean gloves. He/she then proceeded to close the door of the resident's room, pull the privacy curtain, and using the bed remote control he/she raised the bed. […]