Progressive Care Center

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Gas, Vacuum, and Electrical Systems Deficiencies

Have a properly installed medical gas master alarm panel.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

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.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Provide properly protected cooking facilities.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility' s general characteristics.The facility is a one-story, Type II (000) structure. The facility is separated from the hospital building by a 2-hour wall located by the chapel. There is a partial basement that is used for support services only. The facility has a fully supervised automatic sprinkler system NFPA 13 automatic fire sprinkler system. The facility was surveyed .. Through observation during the survey and documentation review, it was determined that the facility failed to meet the Kitchen Hood requirements in accordance with NFPA 101, and NFPA 96. This STANDARD is not met, as evidenced by: 1) In the dining room, there is a model VCS 2000 Ventless Cooking System. Through document review it was determined that that the system was not connected to the Fire Alarm Control Panel. 2) In the dining room, there.. Through observation during the survey and documentation review, it was determined that the facility failed to meet the Sprinkler System- Maintenance and Testing requirements in accordance with NFPA 101, and NFPA 25. This STANDARD is not met, as evidenced by: 1) There was no Hydraulic Calculation or General Information sign on the fire riser.2) Testing documentation indicates that the Back Flow Prevention Device failed the testing. 3) Dry barrel sprink.. Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exit requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) Through observation, when exiting the 600 Hall exit through the exterior, exit signage need to be along the path taking occupants to public way does not have marking to public way.This did not meet the requirement of LSC Sections7.7.3.. Through observation during the survey, it was determined that the facility failed to meet the Egress Door requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The exterior door in the therapy room did not open when tested. It is a double door, and the left door leaf did not operate because the mechanism was not operating properly. This did not meet the requirement of LSC Sections4.6.12.1 Whenever .. Through observation during the survey, it was determined that the facility failed to meet the Hazardous Area- Enclosure requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The Generator Room had open penetrations in the fire-resistant construction.2) The Soiled Utility Room does not resist the passage of smoke due to damage to the door. 3) Room used for oxygen storage has penetrations around the plumbing.. Through observation during the survey, it was determined that the facility failed to meet the Means of Egress-General requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) In the Dining Room, a gate separated the dining area from the food preparation area. The gate failed to meet the egress and door requirements listed in Chapter 7, and this was witnessed in two areas. 2) Near the nurse station to a stairwell to the .. Through observation during the survey, it was determined that the facility failed to meet the Subdivision of Building Spaced- Smoke Barrier Construction requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) At the occupancy separation from the Skilled Nursing Facility, to the kitchen in the hospital occipany, there are open penetrations in the fire rated assembly above the ceiling. 2) Hall 500 had penetrations in the smoke b..

A recertification survey with complaint #CO36038 and #CO37034 was completed on 11/4/24 to 11/7/24. Seven deficiencies were cited. An Emergency Preparedness survey was conducted from 11/4/24 to 11/7/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for the resident that met professional standards of quality care for one (#110) of one resident out of 29 sample residents. Specifically, t.. Based on observations, record review and interviews, the facility failed to ensure one (#110) of one resident out of 29 sample residents received treatment and care in accordance with professional standards of practice.Specifically, for Resident #110, the facility failed to:-Obtain physician' s orders which indicated if it was acceptable to remove the res.. Based on observations, record review and interviews, the facility failed to ensure residents received the proper treatment and assistive devices to maintain hearing and vision for two (#7 and #40) of two out of 29 sample residents.Specifically, the facility failed to:-Ensure Resident #7 received hearing aids and vision services in timely; a.. Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection in two of three units.Specifically, the facility failed to:-Ensure resident rooms were cleaned in .. Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were provided in order to attain the resident' s highest practicable physical, mental and psychological well-being and to provide effective and person-centered care for one (#40) of one resident out of 29 sample residents.Specifically, the .. Based on record review and interviews, the facility failed to take steps to prevent abuse for three (#40, #10 and #35) of three residents reviewed for abuse out of 29 sample residents.Specifically, the facility failed to protect Resident #40, Resident #10 and Resident #35 from physical abuse.Findings include:I. Facility policy and procedureThe Abuse, .. Based on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for one (#29) of five residents out of 29 sample residents.Specifically, the facility failed to ensure the pharmacist' s monthly medication regimen review (MRR) recommendations and the associated physician' s orders to dis.. Based on record reviews and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#38) of one resident reviewed for PASRR out of 29 sample residents.Specifically, the f..

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code Sections 19.7.9.3.1.1. No 90 min test for Emergency lightsNo 90 min test for Exit lightsExit light by room 501 and 700 hallway exit need new batteriesNFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) An annual test shall be conducted on .. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. 2hr fire wall has unprotected penetrations by the chapelNFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Mai.. Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 101, Life Safety Code, Section 19.3.2.1.3.Room 506, Beauty Shop and 700 hallway rooms used as storage need self closers installedNFPA 101, 19.3.2.1.3 Doors. Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 21.2.2.4.These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator .. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills not performed under varied times NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an .. Based on record review, it was determined that the facility failed to maintain the facility laundry chute in accordance with NFPA 101 and NFPA 82. Laundry chute door assembly did not self close from all open positionsNFPA 101 9.5.2 Installation and Maintenance.Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service.This deficiency h.. The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility' s general characteristics.The facility is a one-story, Type II (000) structure. The facility is separated from the hospital building by a 2-hour wall located by the chapel. There is a partial basement that is used for support services only. The facility has a fully supervised automatic sprinkler system NFPA 13 automatic fire sprinkler system. The facility was surveyed on May 10, 2023 for compliance to fire safety requirements using the National Fire Protection Association (NFPA) 201.. Through documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No Receptacle Polarity/Retention inspection available at the time of inspection NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms.6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.6.3.3.2.2 The continuity of the grounding circuit in each electrical rec..