Chautauqua Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the survey the facility failed to ensure the individual financial record was available to the residents through quarterly statements and upon request for six (6) (Resident #18, #19, #136, #138, #164, and #167) of six (6) residents reviewed. Specifically, there was no evidence the facility provided quarterly statements to residents or their representatives and there was no evidence of receipted accounting records for personal fund transactions from the facility's store.The findings are: The policy and procedure titled Financial Affairs dated 10/2016 documented Residents may manage his/her personal financial affairs will be given at least a quarterly accounting of financial transactions made on his/her behalf. A separate receipt book is to be maintained for recording withdrawals. Receipts should include the residents' name, amount withdrawn, and a brief description of what it is for and signed by the residents or the power of attorney on file. When reimbursing…

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 interview and record review conducted during the survey the facility failed to ensure that all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to administrator of the facility and to other officials (including to the State Survey Agency) for six (6) (Resident #18, # 19, #136, #138, #164, and #167) of six (6) residents reviewed. Specifically, the facility did not report to the State Agency when there was reasonable suspicion of misappropriation of resident funds. This resulted in no actual harm with the potential to affect all residents, that is substandard quality of care.The findings are: Refer to F 568 Scope and severity F The policy and procedure titled Facility Incident/Abuse Investigation and Reporting revised 09/2025…

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 interview and record review conducted during the survey the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not provide adequate oversight of the Business Office Manager to ensure adequate accounting and records of personal funds. Additionally, when there was reasonable suspicion of misappropriation of resident funds, it was not reported to the State Agency within the required timeframe.The findings are: REFER TO: F 568 - Accounting and Records of Personal Funds scope and severity F F 609 - Reporting Alleged Violations scope and severity F The policy and procedure titled Financial Affairs dated 10/2016 documented residents may manage his/her personal financial affairs will be given at least a quarterly accounting of financial transactions made on his/her behalf. A separate receipt book is to be maintained for recording withdrawals. Receipts should include the residents…

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, interviews, and record review conducted during the survey the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #7) of one (1) resident reviewed for non-pressure related skin concerns. Specifically, staff did not report, assess, and monitor a skin injury on the resident's right shin. The findings are:The policy and procedure titled Skin Observation dated 06/29/2019 documented to report findings of assessment to the unit manager/supervisor. The unit manager/supervisor will initiate and complete a weekly nursing status documentation. The unit manager/ supervisor will notify the provider and obtain orders for appropriate treatment. Resident #7 had diagnoses of diabetes mellitus, hemiplegia (paralysis that affects one side of the body) affecting the left side, and a history of transient ischemic attack (a temporary blockage of blood flow to the brain). 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.

Based on observations, interviews, and record review conducted during a survey the facility failed to ensure that a resident with a suprapubic Foley catheter (a tube inserted directly into the bladder to drain urine) received appropriate treatment and services to prevent urinary tract infections for one (1) (Resident #10) of three (3) residents reviewed. Specifically, Resident #10's gravity drainage bag (used to collect urine) was not kept below the level of the resident's bladder.The findings are:The policy and procedure titled Catheter (Urinary & Suprapubic) Insertion and Removal last revised 08/2024 documented indwelling and intermittent catheters were utilized, when necessary, based on current professional standards of practice. The facility must ensure that the resident receives appropriate treatment and services to prevent urinary tract infections to the extent possible. To achieve a free flow of urine and maintain infection control, collecting bags were always kept below the level of the bladder.Resident #10 had diagnoses including urinary tract infection, retention of urine,…

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 observations, interviews, and record review conducted during the survey the facility failed to ensure routine inspection, maintenance, and safe functioning of bed frames and mattresses was conducted as part of a regular maintenance program for one (1) (Resident #7) of one (1) resident reviewed. Specifically, Resident #7's bed frame lacked mattress retainers (bars that hold the mattress in place) according to the manufacture's specifications. In addition, routine inspections of beds had not been conducted since 2023.The findings are: The policy and procedure titled Maintenance, module management of environment of care maintenance dated 10/2024 documented the facilities maintenance department is responsible for all equipment and furnishings of the facility are repaired as needed by the maintenance department. Beds, bedtables, headboards, chairs and dressers are maintained in good condition. Resident related medical equipment will be inspected as per manufactures policy, along with preventative maintenance scheduled based on manufacturers' recommendations. Review of 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 interviews and record review conducted during a Complaint Investigation (NY00339323) the facility did not ensure they consulted with the resident's physician when there was a need to alter treatment significantly for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the facility did not ensure they consulted with the resident's physician when a medication was not administered as ordered, resulting in 20 missed doses. The finding is: The policy titled Medication/Treatment Administration Documentation, last revised 6/24, documented when medications or treatments are not available for administration as ordered inform the Nursing Supervisor immediately, Emergency medication kit is used, and the medical provider is notified, and immediate medication delivery is requested. The policy titled Change in Resident's Condition, Medication/Treatment or status, last revised 2/2025, documented the resident and/or responsible party and the attending physician are promptly notified in changes of care and resident condition. Nursing services will notify 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 interview and record review conducted during a Complaint investigation (#NY00339323) the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) met the needs of each resident. Specifically, for one (Resident #1) of three residents reviewed the facility did not ensure medications were acquired and administered in accordance with the physician's orders and professional standards. Resident #1 was not administered 20 doses of their antipsychotic medication. The finding is: The policy titled Ordering Medications/Treatments from Pharmacy, last revised 5/2023, documented medications and treatments would be obtained as prescribed by the prescribing practitioner for individual resident use. The policy titled Medication/Treatment Discrepancy/Error, last revised 3/2011, documented the purpose of the policy was to assure proper medication/treatment administration and compliance with the legal requirements of medication administration and to report all errors in…

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 interview and record review conducted during an Abbreviated survey (Complaint #NY00337078) the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 3 residents reviewed. Specifically, Resident #1 was left alone in the bathroom while attached to a sit to stand lift and had a fall that resulted in a bruise to the side of their head. The finding is: The policy and procedure titled, Accident/Incident Investigation and Prevention, revised on 6/2023, stated the facility provides 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. The policy and procedure titled Interdisciplinary Care Planning, revised on 4/15/2024, stated the comprehensive care plan and [NAME] (guide used by staff to provide care) must always be current and accurately reflect the resident's status. The Care plan/[NAME] must…

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 observation, interview, and record review conducted during the Standard survey completed on 12/1/23, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming, personal and oral hygiene for one (Resident #166) of four residents reviewed. Specifically, a resident who was dependent on staff for hygiene with facial hair was not shaved or offered to be shaved after their shower. The finding is: The policy and procedure (P&P) titled Activities of Daily Living dated 11/2016 documented each resident will receive and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. 1. Resident #166 had diagnoses which included Alzheimer's disease (a type of dementia), depression, and weakness. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/17/23 documented the resident was rarely understood,…

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, interview, and record review conducted during the Standard survey completed on 12/1/23, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for two (Resident #192 and #31) of seven reviewed for quality of care. Specifically, there was lack of wound assessments for Resident #192 and #31 and #192 lacked a care of plan revision to accurately reflect the resident's status. The findings are: The policy and procedure (P&P) titled, Documentation of Pressure Ulcer and Chronic Wounds revision date 6/23 documented pressure ulcers and chronic wounds are monitored closely to monitor effectiveness of treatment and change in risk factors. Pressure, stasis and/or chronic wounds will be monitored daily (with documentation, when a complication or change is identified) which should include observations of the area if no dressing present or status of the dressing, signs/symptoms of possible…

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, interview, and record review conducted during the Standard Survey completed on 10/1/21, the facility did not have the evidence that all alleged violations of abuse, mistreatment and neglect were thoroughly investigated for one (Resident #138) of two residents reviewed. Specifically, the lack of investigation into facial bruising of unknown origin. The finding is: The policy and procedure (P&P) titled Incident Accident Reporting dated 6/21 documented it shall be the policy to distinguish between an accident and incident, but to nevertheless report and investigate both such events through formal, but distinctly different, reporting processes to rule out abuse, neglect, or mistreatment. All incidents are to be reported immediately to the Charge Nurse on duty and Nursing Supervisor will then be notified. For any incident/accident where abuse, neglect, mistreatment, is known or suspected, notify the Director of Nursing and Administrator immediately and begin investigation. The P&P titled Abuse…

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, interview, and record review conducted during the Standard survey completed on 10/1/21 the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs. One (Resident #138) of five residents reviewed for unnecessary medication use was on Seroquel (anti-psychotic medication) without an adequate indication for continued use. In addition, there was no supporting documentation to justify an increased Seroquel dose on 9/21/21 and for continued use of the medication. The finding is: Review of a facility policy entitled Psychotropic Med Use Initiation and Gradual dose reduction dated 3/07 revealed residents were evaluated for the initiation/continued need for psychotropic medications and the determination of whether he/she is being maintained on the lowest effective dose. The Unit Coordinator in concert with the Interdisciplinary Team IDT determines…

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.