Progressive Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to accurately identify each resident's fall risk status by failing to complete the Fall Risk Assessment for 3 (#1, #2, and #3) of 3 total sampled residents.Findings:Review of the facility's Fall Risk Assessment Policy and Procedure with a review date of 04/01/2026 revealed in part: Policy: It is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. Policy Explanation and Compliance Guidelines: 1. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified. 2. The risk assessment will contain the following components:a. Identify environmental hazards and individual risks, including the need for supervision.b. Evaluate and analyze hazards and risks. Resident #1 Review of Resident #1's medical record revealed an admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure 1 (#69) of 1 resident reviewed for wound care received treatment.Findings: Review of Resident #69's medical record revealed an admission date of 03/20/2026 and diagnoses including status post BKA of right lower extremity and status post trans metatarsal [toe] amputation of left foot. Further review of Resident #69's medical record revealed a BIMS score of 15, indicating intact cognition. During an interview on 03/31/2026 at 2:37 p.m. Resident #69 reported surgical dressings on right BKA surgical site and left toe surgical site were not changed for 5 days until 03/25/2026.Review of Resident #69's physician's orders revealed a start date of 03/25/2026 for:-Wound care, surgical: right below knee amputation site (20 staples) clean with wound cleanser, pat dry, wrap in rolled gauze and secure with ace wrapping daily until resolved;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, observations, and interviews the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent infection by:1) failing to ensure staff wash and/or sanitize their hands prior to and in between resident care and medication administration for 2 (#59, #74) of 6 residents observed for medication administration;2) failing to sanitize glucometer machine after use for 1(#59) of 1 resident observed for blood glucose monitoring.Findings: Review of facility policy (no name or date) received 03/31/2026, withPurpose: It is the policy of Progressive Care Center that PCC considers hand hygiene the primary means to prevent the spread of infections.Procedure:6. In most situations, the preferred method of hand hygiene is with soap & water. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations:d. Before preparing or handling medications;j. After removing gloves7. Hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (#60) of 2 resident records reviewed for ADL care.Findings: Review of the facility's Care of Fingernails/Toenails policy revised 10/23/2025 revealed:Nail care includes needed cleaning and regular trimming. Review of Resident #60's medical record revealed an admission date of 03/08/2026 and diagnoses including lung cancer, gout, and atrial fibrillation. Further review of Resident #60's medical record revealed a BIMS score of 12, indicating moderate cognitive impairment. An observation on 03/30/2026 at 11:04 a.m. revealed Resident #60 had long fingernails past the fingertips on both hands with brown substance under fingernails. During an interview on 03/30/2026 at 11:04 a.m. Resident #60 reported feeling unhappy with long fingernails. Resident #60 further reported food gets stuck underneath nails and would like fingernails trimmed.An observation on 03/31/2026 at 8:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure appropriate care and services consistent with professional standards of practice were implemented for 1 of 1 resident (# 19) reviewed for dialysis. The facility failed to ensure Resident #19's dialysis access site was assessed and monitored every shift. Findings: Review of the facility's Monitor Dialysis Site policy dated 12/15/2023 revealed in part: I. The nurse will ensure that the dialysis access site (e.g. [exempli gratia for example] AV [Arteriovenous] shunt or graft) is checked every shift. The nurse will check for a bruit and palpating for a thrill . II. The site will also be monitored every shift for signs and symptoms of infection . Review of Resident #19's medical record revealed an admit date of 06/15/2017 with a re-admission on [DATE] with diagnoses which included, but not limited to, end stage renal disease, chronic kidney disease, and dependence on renal dialysis. Review of Resident #19's current physician's orders revealed an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to ensure, prior to installation and use of bed rails, residents were assessed for the risk of entrapment, a consent was obtained from the resident or resident's representative, and residents had a physician order and care plan for use of bed rails for 7 (#7, #26, #27, #28. #148, #149, #196) out of 7 (#7, #26, #27, #28. #148, #149, #196) residents reviewed for bed rails. Findings: Review of the facility's Proper use of Side Rails dated 08/28/2017 (approved on 09/14/2017) revealed in part: Purpose: It is the policy of _____ that _____ utilize these guidelines to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Procedure: Physical restrains are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#148) of 5 (#11, #32, #36, #148, #149) residents reviewed for unnecessary medications. The facility failed to monitor Resident #148 for bleeding while receiving an anticoagulant and for behaviors and side effects while receiving an antidepressant. Findings: Review of Resident #148's medical record revealed an admission date of 02/18/2025 with diagnoses that included, in part, depression, atherosclerotic heart disease of native coronary artery, heart failure unspecified, and presence of cardiac pacemaker. Review of Resident #148's physician orders revealed a 02/18/2025 order for Eliquis 2.5mg (milligram) tablet - give one tablet by mouth twice a day and 02/18/2025 order for Celexa 10mg tablet - give one tablet by mouth at bedtime. Review of February 2025 MAR (Medication Administration Record) failed to reveal monitoring for bleeding had been conducted with 8:00 a.m. dose of Eliquis on 02/21/2025, 02/22/2025, and 02/24/2025 and the 8:00 p.m. dose of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 2 (Resident #32 and #149) residents out of a total sample of 20 residents. The facility failed to ensure: 1. Enhanced Barrier Precautions (EBP) were in place for Resident #32 and Resident #149; 2. Staff donned with proper Personal Protective Equipment (PPE) when performing high-contact resident care for Resident #149. Findings: Review of the facility's Enhanced Barrier Precautions Policy and Procedure dated 03/25/2024 revealed in part: Policy: It is the policy of ____________ to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism (MDRO). Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for 1 (#1) resident out of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's Abuse Policy (undated) revealed the following: It is the policy of the facility to ensure residents have the right to be free from abuse. It is the responsibility of the employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown origin, and theft or misappropriation of resident property to facility management. Procedure: IV. Comprehensive policies and procedures have been developed to aid in preventing abuse, neglect or mistreatment of our residents. The facility's abuse prevention program at a minimum includes: G. The implementation of changes to prevent future occurrences of abuse. IX. To assist one in recognizing incidents of abuse, the following definitions of abuse are provided: B. Verbal abuse is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure a resident received adequate supervision for 1 (#1) of 3 (#1, #2 and #3) sampled residents who receive a whirlpool bath. Findings: Review on 05/06/2024 of facility's current undated policy titled Giving the Resident a Shower/Whirlpool Policy and Procedure revealed in part: Be sure that the bath area is at a comfortable temperature for the resident. Stay with the resident throughout the bath/whirlpool. Never leave the resident unattended in the tub or shower. Use the emergency call signal to summon assistance, if needed. Review of the facility's Incident Report with occurrence date of 04/12/2024 revealed in part, Resident #1 was left alone in the whirlpool room. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: acquired absence of left leg below the knee, type 2 diabetes mellitus with neuropathy, and hypertensive heart disease. Review of Resident #1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews the facility failed to develop and implement a comprehensive person centered plan of care for 2 residents (#36, #5) out of 14 residents investigated for plan of care. The facility failed to: 1. Develop and implement a plan of care for Resident #36's indwelling catheter. 2. Implement administration of Resident #5's medication as ordered by the physician. Findings: 1. Resident #36 An observation on 02/05/2024 at 8:15 a.m. revealed Resident #36's indwelling catheter bag hanging on Resident #36's bed and draining dark amber urine in catheter bag. Review of Resident #36's nurses notes revealed on 02/05/2024 Resident #36's indwelling catheter was patent and draining dark amber urine. Review of Resident #36's Quarterly MDS dated [DATE] revealed the following diagnoses in part: Heart failure, urinary tract infection, diabetes mellitus, cirrhosis of liver, chronic kidney disease stage 3. Review of Resident #36's physician orders failed to reveal an order for an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day, 7 days a week, for 4 days within FY (Fiscal Year) Quarter 4 2023 (July 1- September 30). Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY Quarter 4 2023 (July 1- September 30) revealed there were no RN hours for four or more days within the quarter. Further review revealed no RN hours for the dates of 07/24/2023, 07/25/2023, 08/07/2023, and 08/08/2023. During an interview on 02/06/2024 at 1:10 p.m. S1 Administrator reported she was responsible for completing the PBJ staffing report. S1 Administrator reviewed the PBJ for FY (Fiscal Year) Quarter 4 2023 (July 1- September 30) and reported during that time period the facility only had one RN. S1 Administrator confirmed there was not RN coverage for at least 8 consecutive hours a day for 07/24/2023, 07/25/2023, 08/07/2023, and 08/08/2023 and there should have been.

Based on interviews and record reviews the facility failed to ensure grievances or complaints were addressed and investigated. The facility failed to follow their policy by ensuring a resident can file a grievance or complaint without fear of threats or reprisal. The facility had a total census of 42 residents. Findings: Review of the facility's Grievance/Complaint policy reveal in part the following: Purpose: It is the policy of this facility to assist its residents, or person on behalf of the resident, in filing grievances or complaints when such requests are made. The following procedure outlines the steps needed to accomplish this task. Procedure: Any resident, his or her representative, family member or appointed advocate, may file grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, missing property, etc., without fear of threat or reprisal. Staff member will delegate the responsibility of the grievance and/or complaint investigation to the department staff member who is best able to carry out the investigation and report the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.