Circle of Care

In the surveyor’s words

From the most serious findings on record at Circle of Care, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Apr 9, 2025

  Based on observation, medical record review, review of the facility water management plan and maintenance logs, review of legionella water test results, review of the Centers for Disease Control and Prevention (CDC) guidance related to legionella, review of infection control tracking, and interviews with staff and representative from the Local Health Department (LHD), the facility failed to develop, implement and follow a comprehensive and effective infection control program/water management plan to prevent the continued presence of legionella bacteria in their water supply. […]

• Actual harm, isolatedF686May 2, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent the development of an avoidable pressure ulcer and failed to promptly identify, monitor/assess and implement effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (#4) of two residents reviewed for pressure ulcers. Actual harm occurred on 03/07/22 when Resident #4, who was at risk for skin breakdown (but admitted with intact skin), cognitively impaired and dependent on staff for all activities of daily living including turning and repositioning, was identified to have an unstageable pressure ulcer (a full-thickness tissue loss with exposed bone, tendon or muscle with slough/eschar present which prevents accurate staging of the ulcer and… […]

• No harm, potential for more than minimal, widespreadF835Apr 9, 2025

  Based on observation, record review, and interview, the facility failed to renew their food service operation license in a timely manner. This affected all 35 residents who received food from the kitchen (except Residents #14, #37, #41, #94, and #96 who had orders for nothing by mouth). The facility census was 40. Findings include: On [DATE] at 7:00 A.M., an initial tour of the kitchen revealed the food service operation license posted on the bulletin board expired on [DATE]. On [DATE] at 7:49 A.M., an interview with Dietary Manager #304 verified the facility's posted food service operation license expired on [DATE]. […]

• No harm, potential for more than minimal, widespreadF868Apr 9, 2025

  Based on review of the facility Quality Assurance and Performance Improvement Program (QAPI) and Quality Assurance (QA) sign-in sheets and meeting minutes, policy review and interview, the facility failed to ensure the QA committee consisted of the minimum required members. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of the QAPI meeting sign-in sheets from July 2024 through February 2025 revealed no evidence of attendance by Medical Director #369. Further review of the sign-in sheets revealed Licensed Practical Nurse (LPN) #302, the current (since 01/04/25) Infection Preventionist (IP) signed the QAPI attendance sheet as the IP on 10/31/24 and 12/19/24 and was not in attendance for the meeting held on 01/30/25. […]

• No harm, potential for more than minimal, widespreadF882Apr 9, 2025

  Based on review of training certificates, personnel files, and interview, the facility failed to ensure staff responsible for overseeing the infection prevention and control program (IPCP) completed specialized training in infection prevention and control. This had the potential to affect all 40 residents residing in the facility. Findings include: Interview on 03/20/25 at 10:32 A.M. with Infection Preventionist (IP) #302 revealed she began training to become the facility's IP toward the end of August 2024, but the previous IP who was responsible for training her quit approximately eight hours into her training, so she had to try to figure out the role on her own. […]