Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Compass Healthcare And Rehab Rowan, Llc during CMS and state inspections, most recent first.
A resident with diabetes, severe cognitive impairment, and dependence on staff for personal hygiene did not receive necessary podiatry care, including toenail trimming, despite repeated requests from the responsible party and a care plan specifying podiatry referral. Staff observed the resident's toenails were long and thick, but communication lapses prevented the resident from being added to the podiatry list or receiving timely care.
Surveyors found that food and beverage items in the nourishment room refrigerator and freezer were not properly dated or labeled, including expired milk and unlabeled personal food items. Staff interviews confirmed that expired milk should not have been present and that nursing staff were responsible for labeling residents' personal food before storage. The dietary department did not supply milk to the nourishment room but maintained a list of items placed there daily.
A resident in a LTC facility received both her own medications and those prescribed for her roommate due to a nurse's failure to verify the resident's identity. The error involved administering incorrect doses of carvedilol and additional medications not prescribed to the resident, leading to increased monitoring and medical assessments to prevent adverse effects.
The facility failed to maintain a clean and safe shower room environment, with observations of feces odor, grime, and disorganization. Staff interviews revealed inconsistent cleaning practices, particularly by the second shift, and a lack of a cleaning schedule. The Director of Housekeeping and the Administrator were unaware of the issues.
A medication error occurred when a nurse administered medications intended for one resident to another during a morning medication pass. The error happened because the nurse did not verify the resident's identity by asking her name, leading to the wrong medications being given. The resident, who was cognitively intact, received her roommate's medications in addition to her own, despite indicating she did not take medications in pudding. The incident was reported to the charge nurse, who informed the physician and facility administration.
Failure to Coordinate Podiatry Care for Dependent Diabetic Resident
Penalty
Summary
The facility failed to arrange or coordinate podiatry care for a dependent resident with multiple diagnoses, including diabetes, muscle weakness, stroke, and severe cognitive impairment. The resident was dependent on staff for personal hygiene and had a care plan that included regular foot inspections, encouragement of proper foot care, referral to a podiatrist, and nail trimming. Despite a physician order allowing podiatrist services and repeated requests from the resident's responsible party for toenail trimming, the facility did not provide this care. The responsible party reported making multiple requests since admission, but the resident's toenails remained untrimmed, and the resident was not added to the podiatry list for the next scheduled visit. Observations confirmed that the resident's toenails were long, thick, and extended beyond the toes. Staff interviews revealed that nurse aides were aware of the need for nail care but did not trim the nails due to the resident's diabetic status, and there was a lack of communication to nursing staff and the facility scheduler regarding the need for podiatry services. The scheduler was unaware of the issue and stated that an outside appointment would have been made if immediate attention was required. The administrator was also unaware of the responsible party's concerns and expected nursing staff to communicate such needs and ensure residents were added to the podiatry list.
Failure to Properly Date, Label, and Dispose of Food Items in Nourishment Room
Penalty
Summary
Surveyors observed that food and beverage items stored in the nourishment room refrigerator and freezer were not properly dated or labeled. Specifically, there were 13 cartons of whole milk with expiration dates that had already passed, as well as a plastic container of peach cobbler and a blueberry bagel wrapped in foil, neither of which were labeled with a resident's name or room number, nor dated. Additionally, two commercially prepared entrees in the freezer section were also found without any labeling or dating. Interviews with dietary staff revealed that expired milk should not have been present in the refrigerator and that the responsibility for dating and labeling residents' personal food items before storage fell to the nursing staff. The dietary department did not supply milk to the nourishment room but did provide a list of food items placed there daily. The dietary manager confirmed that dietary staff were available in the kitchen until 8:30 p.m. each night and that extra milk was supplied upon request. These findings indicate a failure to ensure proper food storage practices in accordance with professional standards.
Medication Error Involving Incorrect Administration to Resident
Penalty
Summary
The facility failed to protect a resident from a significant medication error when a nurse administered medications prescribed for another resident to the wrong individual. During the morning medication pass, Nurse #1 mistakenly gave Resident #26 both her own medications and those prescribed for her roommate, Resident #18. This error included administering an incorrect dose of carvedilol, as well as additional medications such as apixaban, hydralazine, levetiracetam, and aripiprazole, which were not prescribed to Resident #26. Resident #26, who was cognitively intact and had a medical history including cerebrovascular disease, hypertension, and atrial fibrillation, was at risk of complications due to the medication error. The error was discovered when Nurse #2, who had prepared the medications, realized that Nurse #1 had administered both sets of medications to Resident #26. The error was reported to the physician, who ordered immediate monitoring and tests to assess any adverse effects on Resident #26. Interviews with the involved staff and Resident #26 revealed that Nurse #1 did not verify the resident's identity before administering the medications. Resident #26 reported that Nurse #1 did not ask for her name and insisted on taking the medications despite her protest about the method of administration. The physician and nurse practitioner assessed Resident #26 following the error, noting that she was at risk for bleeding, bruising, and hypotension due to the incorrect medications received.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Notify the Medical Director and receive new orders for vital signs every hour for first shift, then vital signs every 2 hours for second shift, then every shift. In addition, Stat EKG, Stat CBC, CMO, PT/INR, CPK.
- Hold the medication Coreg 3.125 mg until the Medical Director can examine Resident #26.
- Complete a Medication Error report and notify family.
- The Nurse Practitioner examines Resident #26 and reports the EKG is reviewed and is normal. Labs are collected and are pending.
- Repeat all labs.
- Interview Nurse #2 by the Administrator to determine if medications had been administered properly for all other residents on the medication pass.
- Ensure no other residents have suffered a serious adverse outcome as a result of the noncompliance.
- Conduct an in-service on Proper Medication Administration (The 5 Rights) for all nurses and medication aides, and reinforce medication administration is not to be conducted jointly at any other time.
- Educate all nurses. Any not educated will be removed from schedule until education is performed.
- Director of Nursing/Designee will keep in-service records and ensure all staff have received education before returning to work.
- Joint Medication Administration is not allowed. Include this topic in the in-service.
- Conduct a Medication Pass Observation for all nurses on duty and continue until all nurses have a medication pass skills observation.
- Remove Nurse #1 from duty until further notice.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a clean and safe shower room environment, as observed during a survey. On multiple occasions, the shower room was found to have a strong odor of feces, brown water, hair, and grime on the walls and floor. Additionally, the room contained two wheelchairs, multiple pairs of shoes, a used razor hanging on an open and unlocked sharps container, and several unlabeled bottles of body wash and shampoo. These observations were made over several days, indicating a persistent issue with cleanliness and organization in the shower room. Interviews with staff, including Nurse Aides #4 and #5, revealed that the shower room was last used two days prior to the initial observation and that it was common for the second shift to leave the room in disarray. Both nursing staff and housekeeping were identified as responsible for cleaning the shower room, but there was a lack of consistent cleaning, particularly by the second shift. The Director of Housekeeping, who was new to the position, was unaware of a cleaning schedule for the shower room and acknowledged the need for immediate deep cleaning and sanitization. The facility's Administrator was also unaware of the environmental concerns in the shower room.
Medication Administration Error Due to Identity Verification Failure
Penalty
Summary
The facility failed to prevent a medication error when Nurse #1 administered medications intended for Resident #18 to Resident #26 during the morning medication pass. Resident #26, who was cognitively intact and had a medical history including cerebrovascular disease, hypertension, and bipolar disorder, received her roommate's medications in addition to her own. The error occurred because Nurse #1 did not verify Resident #26's identity by asking her name, and Nurse #2, who prepared the medications, did not ensure the correct administration. Nurse #1 went to the wrong bedside and administered the medications without confirming the resident's identity, despite Resident #26's indication that she did not take her medications in pudding. The incident was reported by Nurse #2 to Nurse #3, the charge nurse, who then informed the physician, the Administrator, and the Director of Nursing. Resident #26 confirmed that she received her roommate's medications and noted that Nurse #1 did not ask for her name before administering the medications. The physician was notified of the error, and the medication error report was completed by Nurse #3. The failure to adhere to the 5 rights of medication administration led to this error, as both Nurse #1 and Nurse #2 did not properly identify Resident #26 before administering the medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spencer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Care Of Salisbury | 1.3 mi | ★★★★★ | 6 | 0 |
| Nc State Veterans Home - Salisbury | 1.5 mi | ★★★★★ | 12 | 1 |
| Piedmont Health & Rehab Center | 1.9 mi | ★★★★★ | 6 | 1 |
| Salisbury Rehabilitation And Nursing Center | 2.7 mi | ★★★★★ | 17 | 1 |
| Trinity Oaks | 3.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.