Chaffee Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for two residents (Residents #2 and #24) out of seven sampled residents. The facility census was 63. Review of the facility's policy titled, Use of Psychotropic Medications, dated 2026, showed: - It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage services and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected one resident (Resident #35) out of three sampled residents. The facility census was 63. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control when staff failed to implement Enhanced Barrier Precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for two residents (Residents #48 and #65) out of five sampled residents and failed to perform hand hygiene during care for two residents (Residents #48 and #65) out of six sampled residents. The facility census was 63. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of overhead light fixtures. This deficient practice had the potential to affect all residents and staff in the facility. The facility census was 63. The facility failed to provide a policy regarding storing items on top of the overhead light fixtures. Observation on 05/11/26 of resident rooms showed: - At 10:45 A.M., Room Park Avenue (PA)1-A had two pictures, a pot, and a sign on top of light fixture above the bed next to the door; - At 10:45 A.M., Room Main Street (MS) 4-B had ten figurines on top of the light fixture above the resident's bed next to the window; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #8) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts to the event) out of one sampled resident. The facility's census was 59. Review of the facility's policy titled, Trauma Informed Care, undated, showed: - It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 27 opportunities with two errors made, for an error rate of 7.41%, which affected one resident (Resident #4) out of three sampled residents. The facility's census was 59. Review of the facility's policy titled, Administering Oral Medications, reviewed May 2019, showed: - Check the label on the medication and confirm the medication name and dose with the Medication Administration Record (MAR); - Check the medication dose, re-check to confirm the proper dose. Review of the facility's policy titled, Adverse Consequences and Medication Errors, reviewed May 2019, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain appropriate infection control practices by not performing proper hand hygiene and glove changing techniques during incontinent care and medication administration for two residents (Resident #27 and #214) out of 15 sampled residents and two residents (Resident #4 and #37) outside the sample and failed to provide infection prevention precautions by not following enhanced barrier precautions (EBP) for one resident (Resident #15) out of six sampled residents. The facility's census was 59. Review of the facility's policy titled, Personal Protective Equipment, dated May 2024, showed: - Change gloves and perform hand hygiene between clean and dirty tasks and when moving from one body part to another; - Perform hand hygiene before donning gloves and after removal. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer to a hospital, including the reasons for the transfer for five residents (Resident #5, #11, #16, #28 and #38) out of 15 sampled residents. The facility's census was 58. The facility did not provide a facility-initiated transfer policy. 1. Review of Resident #5's medical record showed: - Facility-initiated transfer and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - Facility-initiated transfer and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer and the reason for the transfer to the hospital. 2. Review of Resident #11's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or the legal representative of the bed hold policy at the time of the transfer to the hospital for five residents (Resident #5, #11, #16, #28 and #38) out of 15 sampled residents. The facility's census was 58. Review of the facility's policy titled, Bed Hold Policy, undated, showed: - If the resident's care is paid under the Medicaid Program, Medicaid (a government program that provides health insurance for adults and children) may pay for a certain number of bed hold days; - Resident may request an additional bed hold if days exceed what Medicaid will pay by agreeing to pay the applicable daily rate during the additional bed hold period; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for the use of bed rails and to receive a physician's order prior to installation or use nor did they obtain informed consent from the resident or if applicable, the resident representative for two residents (Resident #16 and #17) out of two sampled residents. The facility's census was 58. Review of the facility policy titled, Proper Use of Bed Rails, undated, showed: - Appropriate alternative approaches are attempted prior to installing or using bed rails; - Medical diagnosis, conditions, symptoms, size and weight, sleep habits, medications, delirium (state of disorientation or confusion), ability to toilet self safely, cognition, communication, mobility, and risk of falling are considered components when determining the resident's needs and whether use of bed rails meets those needs; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses and bed rails as part of a regular maintenance program for two residents with bed rails (Residents #16 and #17) out of two sampled residents. The facility's census was 58. Review of the facility policy titled, Proper Use of Bed Rails, undated, showed: - Maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for bed frames/rails and mattresses; - The facility will assure the correct installation and maintenance of bed rails prior to use. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. [...]