A list of the most recent deficiencies for Compass Park. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-20 | 2023-12-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-20 | 2023-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-08 | 2023-11-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-11-21 | N |
| Post nurse staffing information every day. | Health | 2023-11-08 | 2023-11-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Develop a communication plan. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-19 | 2023-01-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-21 | 2022-12-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-21 | 2022-12-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-21 | 2022-12-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-12 | 2022-06-02 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-23 | 2022-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-23 | 2022-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-23 | 2022-02-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-11-23 | 2022-01-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-22 | 2021-11-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-22 | 2021-11-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-22 | 2021-11-11 | N |
| Dispose of garbage and refuse properly. | Health | 2021-10-22 | 2021-11-11 | N |
