Inspection Report
Re-Inspection
Census: 68
Capacity: 69
Deficiencies: 8
Jun 17, 2024
Visit Reason
A Recertification Survey and complaint investigation were conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including an emergency preparedness survey and a life safety code survey.
Findings
The facility was found to have multiple deficiencies including failure to ensure adequate supervision to prevent accidents, failure to meet professional standards in care plans, failure to notify physicians of unavailable medications, failure to provide 1:1 supervision for residents at risk of aspiration, failure to conduct annual performance reviews for nursing assistants, failure to properly label and store drugs and biologics, failure to maintain infection control practices, and failure to comply with life safety code requirements related to oxygen cylinder storage.
Severity Breakdown
Immediate Jeopardy (IJ): 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure each resident receives adequate supervision to prevent accidents related to supervision when eating. | Immediate Jeopardy (IJ) |
| Failure to meet professional standards of quality in comprehensive care plans. | — |
| Failure to notify physician of unavailable medications and failure to follow physician orders for medication administration parameters. | — |
| Failure to provide 1:1 supervision with meals for residents at risk of aspiration. | — |
| Failure to conduct annual performance reviews for nursing assistants. | — |
| Failure to properly label and store drugs and biologics in accordance with professional principles and state/federal laws. | — |
| Failure to maintain infection prevention and control program to prevent spread of communicable diseases including C. difficile. | — |
| Failure to comply with life safety code requirements for storage and segregation of oxygen cylinders. | — |
Report Facts
Capacity: 69
Census: 68
Deficiencies cited: 8
Medication doses missed: 14
Nursing assistants reviewed: 5
Residents reviewed for supervision: 3
Residents reviewed for medication supervision: 3
Residents reviewed for care plan quality: 3
Residents reviewed for aspiration risk: 3
Medication carts reviewed: 3
Water samples with >1 CFU/ml Legionella: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danny B. Zelko | Administrator | Signed the report and was informed of Immediate Jeopardy status |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 6, 2023
Visit Reason
An off-site desk audit was conducted on July 6, 2023, to review all previous deficiencies cited on May 19, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 2
May 19, 2023
Visit Reason
A Recertification Survey was conducted at Hattie Ide Chaffee Home from 05/16/2023 through 05/19/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including State licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to quality of care and infection prevention and control. Specifically, failures were found in ensuring residents received treatment and care according to professional standards, including offloading heels for residents at risk, and adherence to infection control practices during wound care.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents received treatment and care in accordance with professional standards related to off-loading heels for residents #4 and #5. | SS=E |
| Failure to establish and maintain an infection prevention and control program, including failure to adhere to standard precautions to prevent spread of infections for resident #247. | SS=D |
Report Facts
Survey duration days: 4
Resident IDs cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barry B. Zeltzer | Administrator | Signed the Plan of Correction document dated 06/02/2023 |
| Assistant Director of Nursing (ADNS) | Interviewed regarding resident complaints and care | |
| Director of Nursing Services (DNS) | Interviewed and responsible for implementing corrective plans | |
| Nursing Assistant (NA), Staff A | Interviewed regarding resident care | |
| Registered Nurse (RN) Staff B | Interviewed regarding resident care | |
| Unit Manager, Staff C | Interviewed regarding resident care | |
| Licensed Practical Nurse (LPN) Staff D | Observed and interviewed regarding wound care and infection control | |
| Director of Nursing Services | Interviewed regarding staff compliance with infection control policies |
Inspection Report
Plan of Correction
Deficiencies: 0
May 4, 2022
Visit Reason
An off-site desk audit was conducted on May 4, 2022, to review all previous deficiencies cited on March 31, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 31, 2022
Visit Reason
A Recertification Survey was conducted at Hattie Ide Chaffee Home from 03/28/2022 through 03/31/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to failure to meet professional standards of quality in comprehensive care plans, specifically regarding skin care protocols and physician notification for changes in resident condition. The facility failed to provide evidence that the physician was notified of a resident's skin condition change and initiated treatment without a physician's order.
Deficiencies (1)
| Description |
|---|
| Failure to meet professional standards of quality in comprehensive care plans related to skin care; physician was not notified of change in resident's skin condition and treatment was initiated without a physician's order. |
Report Facts
Resident sample size: 3
Resident ID: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barry B. Kelly | Administrator | Signed the Plan of Correction document |
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