Inspection Reports for
Progressive Care Center
1338 PHAY AVE, CANON CITY, CO, 81212-2311
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 7, 2024
Visit Reason
The investigation was conducted due to allegations of physical abuse involving three residents (#10, #35, and #40) by a certified nursing assistant (CNA #1).
Complaint Details
The complaint investigation was triggered by allegations of physical abuse by CNA #1 against Residents #10, #35, and #40. The investigation included resident interviews, staff interviews, record reviews, and police involvement. The abuse was found unsubstantiated for willful acts, but the facility failed to protect residents adequately.
Findings
The facility failed to protect three residents from physical abuse by CNA #1, who was suspended pending investigation. The internal investigation was unsubstantiated for willful abuse, but residents reported incidents and police were involved. Additionally, the facility failed to develop and implement baseline and comprehensive care plans for some residents, failed to ensure timely ancillary services, and failed to maintain proper infection control practices.
Deficiencies (7)
F 0600: The facility failed to protect Resident #10, #35, and #40 from physical abuse by CNA #1, who was suspended pending investigation. Police were notified and interviewed residents.
F 0655: The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #110, lacking pertinent healthcare information related to a hard cervical collar and fractured left wrist.
F 0656: The facility failed to develop a comprehensive care plan for Resident #40 that included monitoring and care related to anticoagulant medication use.
F 0684: The facility failed to ensure Resident #110 received treatment and care in accordance with orders, including obtaining physician orders for weight bearing status and collar removal, scheduling follow-up appointments, and informing staff of care needs.
F 0685: The facility failed to ensure Resident #7 received timely hearing aids and vision services and Resident #40 received timely vision services.
F 0756: The facility failed to act timely on pharmacist recommendations to discontinue baclofen and guaifenesin for Resident #8, resulting in additional unnecessary doses.
F 0880: The facility failed to maintain an infection control program by not cleaning resident rooms and glucometers according to manufacturer guidelines, including improper glove use, inadequate disinfection contact times, and failure to clean inside toilet bowls.
Report Facts
Residents affected by abuse: 3
Pharmacist recommendation delay: 19
Pharmacist recommendation delay: 4
Staff education signatures: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in physical abuse allegations involving Residents #10, #35, and #40. |
| NHA | Nursing Home Administrator | Conducted abuse investigation and interviewed residents and staff. |
| ADON | Assistant Director of Nursing | Interviewed regarding care plan development and medication regimen review process. |
| DON | Director of Nursing | Interviewed regarding medication regimen review and infection control practices. |
| HSK #1 | Housekeeper | Observed cleaning resident rooms with improper glove use and disinfection practices. |
| LPN #1 | Licensed Practical Nurse | Observed cleaning glucometers improperly and interviewed about cleaning practices. |
| LPN #2 | Licensed Practical Nurse | Interviewed about glucometer cleaning practices. |
| RN #1 | Registered Nurse | Interviewed about glucometer cleaning practices. |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to assess compliance with care and treatment standards for residents in a nursing home setting, focusing on activities of daily living assistance, treatment administration, and skin integrity.
Findings
The facility failed to provide appropriate assistance with activities of daily living to several residents, including timely incontinence care, bathing according to care plans, and oral care. Additionally, treatment orders were not consistently followed, including improper application of creams and failure to monitor and document a resident's bruise.
Deficiencies (2)
F 0677: The facility failed to provide timely incontinence care to Resident #37, bathing according to care plan for Resident #32, and assistance with oral care for Resident #2.
F 0684: The facility failed to investigate and monitor a bruise on Resident #44's forearm and ensure treatment for Resident #20 was administered according to physician orders by qualified staff.
Report Facts
Sample residents reviewed: 29
Residents affected: 5
Incontinence care frequency: 29
Incontinence care once a day: 9
Incontinence care twice a day: 14
Incontinence care three times a day: 6
Showers received by Resident #32 in January 2023: 3
Showers received by Resident #32 in February 2023: 6
Showers received by Resident #32 in March 2023: 9
Showers received by Resident #32 in April 2023: 1
Inspection Report
Routine
Deficiencies: 11
Date: Apr 20, 2023
Visit Reason
Routine state inspection of Progressive Care Center to assess compliance with healthcare regulations including resident care, safety, and infection control.
Findings
The facility had multiple deficiencies including failure to timely resolve resident grievances, prevent resident-to-resident abuse, comprehensively care plan use of restraints, provide adequate assistance with activities of daily living, ensure appropriate treatment and care for residents, maintain safe environment to prevent accidents, provide proper respiratory care, dementia care, dental care, safe food handling, and infection control practices.
Deficiencies (11)
F 0585: The facility failed to resolve a grievance filed by Resident #19 regarding late medication administration, with medications often given hours after scheduled times.
F 0600: The facility failed to prevent resident-to-resident physical abuse when Resident #34 hit Resident #31, and did not ensure effective interventions to prevent further incidents.
F 0657: The facility failed to comprehensively assess and care plan the use of a wheelchair lap tray for Resident #36, lacking a release schedule communicated to staff.
F 0677: The facility failed to provide timely incontinence care for Resident #37, adequate bathing per plan for Resident #32, and oral care assistance for Resident #2.
F 0684: The facility failed to investigate and monitor a bruise on Resident #44's forearm and failed to ensure treatment for Resident #20 was administered by qualified staff according to physician orders.
F 0686: The facility failed to ensure the environment was free from accident hazards by leaving medications at Resident #53's bedside, failing to have RN assessments post falls for Residents #57 and #36, and failing to prevent Resident #57's elopement.
F 0695: The facility failed to obtain a physician's order for continuous oxygen use for Resident #61 and failed to administer oxygen per physician's order for Resident #266.
F 0744: The facility failed to provide personalized interventions to address Resident #34's dementia-related behaviors, resulting in a resident altercation and inadequate environmental controls.
F 0790: The facility failed to provide timely dental services for Resident #53, resulting in delayed follow-up and unresolved denture needs.
F 0812: The facility failed to maintain safe food holding temperatures during meal service, with multiple hot foods held below required temperatures increasing risk of foodborne illness.
F 0880: The facility failed to maintain infection control during wound care for Resident #28, including inadequate hand hygiene, sharing and improper sanitization of wound care scissors, and improper glove use.
Report Facts
Residents sampled: 29
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Food temperature: 103
Food temperature: 130
Food temperature: 104
Food temperature: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in wound care infection control deficiency and medication storage |
| NHA | Nursing Home Administrator | Interviewed regarding grievance, abuse, dementia care, elopement, dental care, respiratory care |
| DON | Director of Nursing | Interviewed regarding medication administration, fall assessments, respiratory care, wound care |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding incontinence care, skin care, oral care |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding Resident #34 behavior and oral care |
| SSD | Social Services Director | Interviewed regarding dementia care, dental care |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding oxygen therapy for Resident #266 |
| NS #1 | Nutritional Specialist | Interviewed regarding food temperature control |
| CDC | Corporate Dietary Consultant | Interviewed regarding food temperature control |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 6, 2022
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to provide meal assistance, pressure ulcer care, and accident hazard prevention for residents.
Complaint Details
The visit was complaint-related due to allegations of failure to provide meal assistance, pressure ulcer care, and accident prevention. The complaints were substantiated based on observations, record reviews, and staff interviews.
Findings
The facility failed to provide adequate meal assistance to residents #37 and #43, resulting in poor nutrition intake. The facility also failed to implement appropriate interventions to prevent pressure ulcers for residents #14 and #38, leading to actual harm. Additionally, the facility failed to prevent falls and adequately investigate and document incidents for residents #14 and #39, resulting in injuries including a hip fracture.
Deficiencies (3)
F 0677: The facility failed to provide meal assistance to residents #37 and #43, resulting in minimal food intake and potential nutritional risk.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for resident #14, resulting in an unstageable deep tissue injury to the left lateral ankle.
F 0689: The facility failed to ensure a safe environment and adequate supervision to prevent accidents, resulting in multiple falls and injuries for residents #14 and #39.
Report Facts
Residents reviewed: 24
Residents affected by meal assistance deficiency: 2
Residents affected by pressure ulcer deficiency: 2
Residents affected by accident hazard deficiency: 2
Braden Scale score: 12
Braden Scale score: 16
Fall risk assessment score: 16
Fall risk assessment score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Named in meal assistance deficiency for Resident #37 and #43 |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding meal assistance for Resident #37 |
| Director of Nursing | Director of Nursing | Interviewed regarding meal assistance and fall prevention |
| Wound Certified Nurse | Wound Certified Nurse | Interviewed regarding pressure ulcer care for Resident #14 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding fall prevention and resident care |
| CNA #1 | Certified Nurse Aide | Interviewed regarding fall prevention and resident transfers |
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