Chautauqua Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 12/01/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in all rooms and sleeping areas with fuel-burning appliances, and on-going preventative maintenance of carbon monoxide detectors. This affected three (Ground, First, and Second floors) of three resident use floors and one of one Basement.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]