A list of the most recent deficiencies for Blue Circle Rehab and Nursing. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-27 | 2024-01-04 | 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 | 2023-10-27 | 2023-12-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-27 | 2023-12-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-27 | 2023-12-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-10-27 | 2023-12-06 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-10-27 | 2023-12-06 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-10-27 | 2023-12-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-27 | 2023-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-27 | 2023-12-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-27 | 2023-12-06 | 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 | 2023-10-27 | 2023-12-06 | 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 | 2023-10-27 | 2023-12-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-27 | 2023-12-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-27 | 2023-12-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-27 | 2023-12-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-27 | 2023-12-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-27 | 2023-12-06 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-27 | 2023-12-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-27 | 2023-12-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-27 | 2023-12-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-27 | 2023-12-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-12-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-27 | 2023-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-27 | 2023-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-27 | 2023-12-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-29 | 2023-09-19 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-25 | 2023-06-23 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-24 | 2023-06-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-25 | 2023-06-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-25 | 2023-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-06-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-25 | 2023-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-24 | 2023-06-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-24 | 2023-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-24 | 2023-06-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-24 | 2023-06-22 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-03-24 | 2023-05-05 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-30 | 2020-12-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-10-30 | 2020-12-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-30 | 2020-12-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-10-30 | 2020-12-14 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-10-30 | 2020-12-14 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-10-30 | 2020-12-14 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-10-30 | 2020-12-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-10-30 | 2020-12-14 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2020-10-30 | 2020-12-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-10-30 | 2020-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-30 | 2020-12-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-30 | 2020-12-14 | 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 | 2020-10-30 | 2020-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-30 | 2020-12-14 | 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 | 2020-10-30 | 2020-12-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-10-30 | 2020-12-14 | 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 | 2020-10-30 | 2020-12-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-30 | 2020-12-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-10-30 | 2020-12-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-10-30 | 2020-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-30 | 2020-12-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-10-30 | 2020-12-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-10-30 | 2020-12-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-10-30 | 2020-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-30 | 2020-12-14 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2020-10-30 | 2020-12-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-10-30 | 2020-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-30 | 2020-12-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-30 | 2020-12-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-10-30 | 2020-12-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-30 | 2020-12-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-30 | 2020-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-30 | 2019-06-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-30 | 2019-06-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-30 | 2019-06-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-30 | 2019-06-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-30 | 2019-06-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-30 | 2019-06-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-30 | 2019-06-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-30 | 2019-06-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-30 | 2019-06-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-30 | 2019-06-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-30 | 2019-06-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-30 | 2019-06-12 | N |
