Compass Healthcare And Rehab Hawfields, Inc.
Compass Healthcare and Rehab Hawfields, Inc. in Mebane, NC — inspection on January 23, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
with pain medication administration.
Record review of the Investigation Report, completed by the
had one medication card, which contained 53 tablets of Oxycodone 5 mg, that was unable to be
attempts to conduct a telephone interview with Nurse #1 on 1/21/26 at 1:45 PM and 1/22/26 at 9:30 AM were not successful.
Nurse #1 was not available for interview. On 1/22/26 at 9:15 AM, during an interview, Resident #2 indicated that she received pain medications every day and had no concerns related to pain management. On 1/22/26 at 10:35 AM, during a phone interview, the Pharmacy Manager indicated that when narcotics were sent from the pharmacy to the facility, each narcotic medication pack was sent with an individual count down sheet. He confirmed that on 10/7/25, the facility notified the pharmacy about alleged drug diversion with Oxycodone 5 mg tablets.
The facility submitted new prescription for Oxycodone 5 mg tablets.
The Pharmacy Manager stated that according to the facility, the affected resident continued to receive her narcotics per order with no pain management interruption. On 1/23/26 at 12:30 PM, during an interview, the Director of Nursing (DON) indicated that a complete investigation was initiated when it was discovered that Resident 2's Oxycodone medication and substance control sheet were missing from the medication cart.
She stated that on 10/7/25, Medication Aide #1 and SDC reported that Resident 2's narcotic and control sheets were missing.
The investigation included reviewing the staff schedule of all person's working the A-hall medication cart from 10/6/25 to 10/7/25.
The SDC reported that narcotic card for Resident #2 with 60 tablets of Oxycodone 5 mg was delivered to the facility on 1/3/26, which was verified with pharmacy.
The DON, SDC and Unit Coordinator audited all the pertinent pharmacy packing slips, MARs, prescription order tracking records, controlled medication return sheets and comparing controlled medication in all the medication carts. It was found that a total of 53 tablets of Oxycodone 5 mg for Resident #2 were missing and Resident #2 was the only resident affected by this incident.
All the staff members, who worked on A-hall medication cart on 10/6/25 to 10/7/25 indicated they did not remove the narcotic medication card or narcotic count sheet for Resident #2 from the medication cart.
The facility could not contact Nurse #1 and she did not come to work her next shift on 10/8/25.
The Administrator reported the incident to the Department of Health and Human Services (DHHS), Law Enforcement agency, North Carolina Board of Nursing, and Medical Director.
The missing Oxycodone was reordered and paid for by the facility.
All residents were assessed, and alert and oriented residents were interviewed for possible harm. In-service related to narcotic accountability and process was conducted to all the current employees and agency staff.
The DON, SDC and Unit Coordinator completed the audit of all medication carts and the documentation for residents, who received controlled substance once weekly for 4 weeks and then monthly for 2 months.
The audit report was presented to Quality Assurance Performance Improvement (QAPI) meeting for 3 months.
After the incident, she did not recall having any additional incident related to controlled medication discrepancies or drug diversion. In result of investigation, Nurse #1 was terminated.On 1/22/26 at 1:00 PM, during the phone interview, the Medical Director indicated the facility notified her immediately about alleged drug diversion incident on 10/7/25.
She confirmed the affected resident (Resident #2) was assessed immediately without any adverse consequences noted.
The missing pain medication was obtained from the Pyxis backup system without delays.
The Medical Director expected the nurses to use the Pyxis backup medication until the missing medications were replaced.
The Medical Director continued that the new prescription for Oxycodone 5 mg tablets was submitted to the pharmacy on 10/7/25.
The facility provided a plan of correction that was not acceptable to the State Agency as the facility did not present interventions to prevent misappropriation of resident's property (narcotic medications for Resident #2).
345363 01/23/2026
Compass Healthcare and Rehab Hawfields, Inc. 2502 S NC 119 Mebane, NC 27302
authorities.
procedure in the area of reporting when the facility failed to report an abuse allegation to the State
of 1 resident reviewed for misappropriation of residents' property (Resident #2).The findings included:The facility's Abuse and Neglect Prohibition policy last revised 6/12/25 indicated that each resident had the right to be free from abuse which included misappropriation of property which was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.
The allegations are reported immediately, but no later than 2 hours if the events that cause the allegation involve abuse or result in serious injury, or no later than 24 hours if the events that cause the allegations do not involve abuse or result in serious injury to the Administrator, and other officials (including to the State Survey Agency and Adult Protection Services were state law provides for jurisdictions in long-term care facilities).
This included an allegation regarding any individual against whom an allegation was made.
The Administrator or designee will ensure that a completed Initial Allegation Report is submitted to DHSR in the required timeframe.
The Administrator or designee will ensure that a report of the investigation is submitted within 5 working days of the allegation using the DHSR Investigation Report.
Record review of the Initial Allegation Report, completed by the Administrator, revealed the facility became aware of misappropriation of resident property on 10/7/25 when the Staff Development Coordinator (SDC) and Director of Nursing (DON) notified the Administrator that Resident #2 had missing narcotics and the medications were unable to be located in the facility.
The Administrator submitted an Initial Allegation Report to the Division of Health Service Regulation for misappropriation of resident property for Resident #2 on 10/10/25.
The police department was notified of suspicion of crime on 10/10/25 at 5:00 PM.
The report did not indicate Adult Protective Services was notified.
Record review of the Investigation Report, completed by the Administrator on 10/16/25, revealed that the allegation of misappropriation of resident property for Resident #2 was substantiated by the facility.
The facility's investigation indicated that Resident #2 had one medication card, which contained 53 tablets of Oxycodone 5 mg, that was unable to be located in the facility.
Nurse #1, named in the investigation report, was terminated.
The Nursing Board and Law Enforcement were notified of the missing narcotics. On 1/23/26 at 1:10 PM, during an interview, the Administrator indicated that on 10/7/25, he was notified of the narcotic discrepancy with one of the medication carts at the facility, but it was not confirmed until 10/10/25. He continued the DON, SDC and nursing staff initiated the investigation to locate the missing medications and after pharmacy confirmation and full search of the facility, the missing narcotics were confirmed.
The Administrator stated that the facility replaced the missing narcotics for the resident immediately to prevent medication treatment interruption. He did not report the allegation to the State until 10/10/25, because the facility was not sure if the narcotics were missing.
The Administrator continued that the facility did not report the allegation to the Adult Protective Service (APS) because the resident was not affected by the situation.
The facility reported the drug diversion to the Law Enforcement, North Carolina Board of Nursing, substantiated the allegation and terminated the accused employee Nurse #1.
The facility was unable to speak with Nurse #1 about the missing narcotics.
The Administrator confirmed that the facility was unable to locate Resident 2's missing narcotics, that the narcotics were removed from the facility, and that Nurse #1 was the named nurse in the allegation.