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Deficiency Records for Circle of Care
A list of the most recent deficiencies for Circle of Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Circle of Care. 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? |
|---|---|---|---|---|
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-04-23 | 2024-05-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-03 | 2023-08-25 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-05-02 | 2022-05-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-02 | 2022-05-31 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-02 | 2022-05-31 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-05-02 | 2022-05-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-02 | 2022-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-02 | 2022-05-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-02 | 2022-05-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-02 | 2022-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-02 | 2022-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-02 | 2022-05-31 | N |
| Report COVID19 data to residents and families. | Health | 2022-05-02 | 2022-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-27 | 2022-05-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-27 | 2022-05-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-03 | 2019-08-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-03 | 2019-08-28 | 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 | 2019-07-03 | 2019-08-28 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-03 | 2019-08-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-07-03 | 2019-08-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-07-03 | 2019-08-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-03 | 2019-08-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-03 | 2019-08-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-07-03 | 2019-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-03 | 2019-08-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-01 | 2019-08-28 | 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 | 2019-07-01 | 2019-08-28 | 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 | 2019-07-01 | 2019-08-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-07-01 | 2019-08-28 | 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 | 2019-07-01 | 2019-08-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Have a properly installed and maintained dumbwaiter or escalator. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-07-01 | 2019-08-28 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-06-21 | 2018-08-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-06-21 | 2018-08-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-06-21 | 2018-08-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-06-21 | 2018-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-21 | 2018-08-10 | 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 | 2018-06-21 | 2018-08-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-21 | 2018-08-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-21 | 2018-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-21 | 2018-08-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-06-21 | 2018-08-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-06-21 | 2018-08-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-06-21 | 2018-08-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-06-21 | 2018-08-10 | N |
| 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 | 2018-06-21 | 2018-08-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-06-19 | 2018-08-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-06-19 | 2018-08-10 | 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 | 2018-06-19 | 2018-08-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-19 | 2018-08-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-19 | 2018-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-19 | 2018-08-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-06-19 | 2018-08-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-19 | 2018-08-10 | N |
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