Deficiency Records for Compass Healthcare and Rehab Hawfields, Inc
Updated as of April 01, 2024
A list of the most recent deficiencies for Compass Healthcare and Rehab Hawfields, Inc. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-03 | 2023-12-15 | N |
| 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 | 2023-11-03 | 2023-12-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-03 | 2023-12-15 | 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 | 2023-11-03 | 2023-12-15 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-11-03 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-03 | 2023-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-03 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-03 | 2023-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-03 | 2023-12-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-07-28 | 2023-08-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-28 | 2023-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-28 | 2023-08-23 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-07-19 | 2022-08-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-19 | 2022-08-05 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-07-19 | 2022-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-21 | 2022-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-07-19 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-28 | 2022-06-21 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-07 | 2022-03-20 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-12-16 | 2022-01-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-12-16 | 2022-01-20 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-16 | 2022-01-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-16 | 2022-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-23 | 2021-04-23 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-10 | 2019-12-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-10 | 2019-12-30 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-11-08 | 2019-12-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-08 | 2019-12-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-11-08 | 2019-12-04 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-11-08 | 2019-12-04 | N |
