Inspection Reports for
Chautauqua Health and Rehabilitation
1205 LEITCHFIELD RD., OWENSBORO, KY, 42303
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
140% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Census: 125
Deficiencies: 1
Date: Apr 4, 2025
Visit Reason
A Standard Recertification and Abbreviated Survey was initiated on 04/01/2025 and concluded on 04/04/2025 to investigate compliance with 42 CFR 483 subpart B, focusing on Quality of Care and Infection Control.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficient practice was identified at the highest Scope and Severity of a "D" related to Quality of Care and Infection Control. The facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to prevent transmission of communicable diseases.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Report Facts
Facility Census: 125
Sample Size: 26
Supplemental Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding nursing staff responsibilities for changing residents' enteral tube-feed bags |
| Director of Nursing | Director of Nursing | Interviewed and assessed residents; responsible for infection control and nursing staff education |
| Assistant Director of Nursing | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control policies and staff expectations |
| Administrator | Administrator | Interviewed regarding staff expectations for infection control and cleaning procedures |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 4, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, focusing on compliance with policies designed to prevent the development and transmission of communicable diseases and infections.
Findings
The facility failed to maintain an effective infection prevention and control program for 2 of 26 sampled residents, specifically related to improper handling of soiled linens, failure to perform hand hygiene and glove changes, and failure to clean and disinfect soiled air mattresses and infusion stands holding enteral feeding bags.
Deficiencies (3)
Failure to perform hand hygiene and glove changes during incontinence care for Resident R97, including using soiled sheets to wipe the mattress and throwing sheets on the floor.
Failure to clean/disinfect the air mattress after providing incontinence care for Resident R97.
Infusion stand holding Resident R1's enteral feeding bag was soiled with unidentified brownish matter and was not cleaned/disinfected as required.
Report Facts
Residents sampled: 26
Residents affected: 2
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | Licensed Practical Nurse (LPN) | Interviewed regarding responsibility for changing enteral tube-feed bags and infection control practices |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for infection control practices and staff compliance |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON)/Infection Preventionist | Interviewed regarding infection control policies and staff education |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding cleaning procedures for air mattresses and housekeeping responsibilities |
| Administrator | Administrator | Interviewed regarding expectations for nursing staff infection control practices and cleaning of soiled equipment |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 2, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication administration policies, and infection prevention and control practices at Chautauqua Health and Rehabilitation.
Findings
The facility failed to ensure proper medication administration practices by pre-pulling medications for residents on the Dementia unit, posing a safety risk. Additionally, infection prevention and control deficiencies were identified, including improper handling of soiled linens, failure to perform hand hygiene and glove changes, and failure to clean and disinfect soiled equipment such as infusion stands for enteral feeding bags.
Deficiencies (2)
Pre-pulled medications for residents on the Dementia unit were found in medication cups marked with resident names, posing a risk for medication errors.
Failure to establish and maintain an infection prevention and control program, including improper handling of soiled linens, failure to perform hand hygiene and glove changes, and failure to clean/disinfect soiled equipment for 2 of 26 sampled residents.
Report Facts
Residents sampled: 26
Residents affected: 3
Residents affected: 2
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Tech 3 | Medication Technician | Observed pre-pulling medications and acknowledged the unsafe practice |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for medication administration and infection control practices |
| Administrator | Administrator | Interviewed regarding expectations for medication administration and infection control practices |
| Certified Nursing Assistant 8 | Certified Nursing Assistant | Observed providing incontinence care with infection control deficiencies |
| Certified Nursing Assistant 10 | Certified Nursing Assistant | Observed providing incontinence care with infection control deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control policies and education |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding cleaning procedures for air mattresses |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding infection control practices related to enteral feeding tube care |
Inspection Report
Deficiencies: 13
Date: Aug 27, 2021
Visit Reason
The inspection was conducted to investigate multiple deficiencies related to resident dignity, abuse prevention, care planning, pressure ulcer care, falls, catheter care, behavioral health services, dietary services, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity, failure to protect residents from abuse and neglect, failure to report and investigate abuse allegations timely, failure to implement care plans, failure to provide appropriate pressure ulcer care and fall prevention, failure to secure urinary catheters, failure to provide appropriate behavioral health care, failure to ensure qualified dietary management and proper food service, failure to maintain infection control practices, and failure to maintain complete and accurate medical records. Immediate Jeopardy was identified related to abuse and behavioral health care but was removed after the facility implemented corrective actions.
Deficiencies (13)
Failure to ensure resident dignity related to residents being undressed or catheter bags not covered.
Failure to protect residents from physical, verbal, and sexual abuse, including failure to investigate and report abuse allegations timely.
Failure to develop and implement care plans addressing physical behaviors and fall prevention interventions.
Failure to provide nail care and shaving for dependent residents.
Failure to provide appropriate pressure ulcer care and complete weekly wound assessments.
Failure to ensure fall investigations were completed after falls occurred.
Failure to secure indwelling urinary catheter to prevent trauma or accidental dislodgement.
Failure to ensure oxygen therapy was administered per physician's orders.
Failure to provide necessary behavioral health care and services to residents with behavioral issues.
Failure to ensure menus and recipes were followed and food was prepared and stored according to professional standards.
Failure to maintain infection control practices including catheter care, social distancing, and mask wearing.
Failure to maintain complete, accurate, and accessible medical records including insulin administration and blood glucose monitoring.
Failure to ensure an effective Quality Assurance program was in place to identify and correct deficiencies.
Report Facts
Residents affected: 3
Residents affected: 5
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #5 | CNA | Named in dignity and catheter care findings |
| Certified Nurse Aide #6 | CNA | Named in dignity and catheter care findings |
| Certified Nurse Aide #2 | CNA | Named in catheter care and privacy bag findings |
| Registered Nurse #1 | RN | Named in catheter care and privacy bag findings |
| Licensed Practical Nurse #6 | LPN | Named in abuse and resident-to-resident altercation findings |
| Certified Nurse Assistant #1 | CNA | Named in abuse and resident-to-resident altercation findings |
| Certified Nurse Assistant #2 | CNA | Named in abuse and resident-to-resident altercation findings |
| Licensed Practical Nurse #7 | LPN | Named in abuse and resident-to-resident altercation findings |
| Licensed Practical Nurse #3 | LPN | Named in behavioral health findings |
| Activity Assistant | AA | Named in behavioral health findings |
| Social Service Director | SSD | Named in behavioral health findings |
| Director of Nursing | DON | Named in multiple findings including abuse, catheter care, behavioral health, falls, and wound care |
| Nursing Home Administrator | NHA | Named in multiple findings including abuse, catheter care, behavioral health, falls, and wound care |
| Dietary Manager | DM | Named in dietary management findings |
| Registered Dietitian | RD | Named in dietary management findings |
| Regional Director of Culinary Services | RDCS | Named in dietary management findings |
| Business Office Manager | BOM | Named in bed-hold notice findings |
| Certified Nurse Assistant #7 | CNA | Named in fall care plan findings |
| Certified Nurse Assistant #3 | CNA | Named in catheter care findings |
| Licensed Practical Nurse #5 | LPN | Named in oxygen therapy findings |
| Licensed Practical Nurse #9 | LPN | Named in infection control findings |
| Unit Manager #1 | UM | Named in infection control findings |
Inspection Report
Routine
Deficiencies: 15
Date: Jul 25, 2019
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, environment, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate call light accessibility, failure to maintain a safe and clean environment, incomplete care plans, improper wound and catheter care, unsafe medication practices, failure to post nurse staffing data, and inadequate infection prevention and control practices.
Deficiencies (15)
Failure to treat two residents with dignity during meals, including not providing utensils and feeding while standing.
Failure to provide accessible call lights for one resident, with call light attached to privacy curtain out of reach.
Failure to maintain a safe, clean, comfortable environment; soiled privacy curtain not replaced.
Failure to develop and implement a baseline care plan for a resident with a urinary catheter within 48 hours of admission.
Failure to revise comprehensive care plan for a resident with a new pressure ulcer.
Failure to provide wound care and gastrostomy tube site care according to care plan and infection control standards for two residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for two residents, including lack of weekly skin assessments and improper wound care technique.
Failure to provide a safe environment; presence of weapons and unsecured medications in resident rooms.
Failure to complete personal belongings checklist on admission for a resident who threatened self-harm with a knife.
Failure to provide appropriate catheter care to prevent urinary tract infections for one resident.
Failure to ensure feeding tubes are used only with medical reason and resident agreement; failure to assess and obtain physician order for self-administration of feeding and medications.
Failure to provide safe and appropriate respiratory care including failure to change oxygen tubing, nebulizer masks, suction tubing and canisters weekly as per policy.
Failure to post nurse staffing information daily at the beginning of each shift.
Failure to ensure insulin pens were dated when opened and expired insulin pens were removed from medication carts.
Failure to establish and maintain an infection prevention and control program including lack of isolation signage and failure to wash hands during wound and gastrostomy tube care.
Report Facts
Residents sampled: 28
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Insulin carts observed: 5
Insulin pens expired: 3
Insulin pens not dated: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Named in dignity and respiratory care findings |
| LPN #1 | Licensed Practical Nurse | Named in gastrostomy tube care deficiency |
| ADON | Assistant Director of Nursing | Named in wound care and catheter care deficiencies |
| DON | Director of Nursing | Named in multiple findings including dignity, wound care, infection control, and medication management |
| Unit Manager | Named in dignity, care plan, and personal belongings checklist deficiencies | |
| CMA #5 | Certified Medication Aide | Named in medication storage and safety deficiency |
| APRN | Advanced Practice Registered Nurse | Named in resident safety and weapon incident |
| Housekeeping Supervisor | Named in privacy curtain deficiency | |
| Administrator | Named in privacy curtain and staffing posting deficiencies | |
| Nurse Practitioner | Named in feeding tube self-administration deficiency |
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