Inspection Reports for
Chautauqua Nursing and Rehabilitation Center
10836 Temple Road, Dunkirk, NY, 14048
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Mar 5, 2025
Visit Reason
Two standard health deficiencies related to notification of changes and pharmacy services, both corrected by May 3, 2025.
Findings
Two standard health deficiencies related to notification of changes and pharmacy services, both corrected by May 3, 2025.
Deficiencies (2)
Notify of changes (injury/decline/room, etc.)
Pharmacy srvcs/procedures/pharmacist/records
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to consult with a resident's physician when a medication was not administered as ordered, resulting in missed doses.
Complaint Details
The complaint investigation (#NY00339323) found that the facility failed to consult with the resident's physician when medication was not administered as ordered, resulting in 20 missed doses of Nuplazid for Resident #1. The facility did not notify the physician of the missed doses or reorder the medication timely, despite policies requiring notification and reordering every 14 days due to insurance restrictions.
Findings
The facility failed to ensure that Resident #1's antipsychotic medication, Nuplazid, was reordered and administered as prescribed, leading to 20 missed doses. The facility did not notify the physician of the missed doses or the need to reorder the medication, violating their own policies and professional standards.
Deficiencies (2)
F 0580: The facility did not consult with Resident #1's physician when a medication was not administered as ordered, resulting in 20 missed doses of Nuplazid. The facility failed to notify the physician of the missed doses or the need to reorder the medication.
F 0755: The facility did not ensure pharmaceutical services met the needs of Resident #1, failing to acquire and administer medications according to physician orders. Resident #1 was not administered 20 doses of their antipsychotic medication due to reordering lapses.
Report Facts
Missed medication doses: 20
Medication reorder interval: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager #1 | Licensed Practical Nurse Unit Manager | Documented Resident #1's medication orders and progress notes; interviewed regarding medication reordering. |
| Licensed Practical Nurse Unit Manager #2 | Licensed Practical Nurse Unit Manager | Interviewed about medication reordering issues and lapses for Resident #1. |
| Physician #1 | Physician | Documented Resident #1's psychiatry consult and medication orders. |
| Neurologist/Psychiatrist | Neurologist/Psychiatrist | Ordered Nuplazid for Resident #1 and provided expert opinion on medication importance. |
| Assistant Director of Nursing | Assistant Director of Nursing (interim Director of Nursing) | Interviewed regarding medication reordering responsibilities and lapses. |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed about medication review and importance of Nuplazid administration. |
| Medical Director | Medical Director | Interviewed about expectations for medication administration and notification of lapses. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 12, 2024
Visit Reason
One standard health deficiency for accident hazards and supervision, corrected by September 24, 2024.
Findings
One standard health deficiency for accident hazards and supervision, corrected by September 24, 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 12, 2024
Visit Reason
The visit was conducted as an abbreviated survey triggered by a complaint (Complaint #NY00337078) regarding inadequate supervision of a resident leading to a fall.
Complaint Details
The complaint investigation found Resident #1 was left alone in the bathroom attached to a sit to stand lift, resulting in a fall and injury. Staff interviews revealed lack of awareness of care plan requirements and failure to supervise as directed. The complaint was substantiated with findings of minimal harm.
Findings
The facility failed to ensure adequate supervision and use of assistive devices for Resident #1, who fell while left alone on the toilet attached to a sit to stand lift. Staff were not consistently aware of or following the resident's care plan interventions, resulting in a minimal harm incident.
Deficiencies (1)
F 0689: The facility did not ensure that Resident #1 received adequate supervision while on the toilet, resulting in a fall with injury. Staff failed to follow the care plan requiring supervision and two-person assist with the sit to stand lift.
Report Facts
Residents reviewed: 3
Residents affected: 1
Date of fall: Mar 6, 2024
Date of care plan intervention: Mar 9, 2022
Date of care plan intervention: Oct 4, 2022
Date of staff education: Mar 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in fall incident and education for failure to follow care plan | |
| Registered Nurse #1 | Educator Inservice Coordinator | Provided education to CNA #1 and assessed resident after fall |
| Registered Nurse #2 | Assessed Resident #1 after fall | |
| Registered Nurse #3 | Documented nurse progress note after fall | |
| Licensed Practical Nurse #1 | Responded to fall incident | |
| Licensed Practical Nurse #2 | Former Unit Manager | Assessed fall situation and started investigation |
| Director of Nursing | Director of Nursing | Provided statements on supervision expectations and education |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Findings
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Findings
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Findings
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Findings
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 18, 2023
Visit Reason
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Findings
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Findings
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Dec 1, 2023
Visit Reason
Multiple standard health and life safety code deficiencies related to ADL care, infection control, licensing, quality of care, and various life safety code issues, all corrected by January 30, 2024.
Findings
Multiple standard health and life safety code deficiencies related to ADL care, infection control, licensing, quality of care, and various life safety code issues, all corrected by January 30, 2024.
Deficiencies (15)
ADL care provided for dependent residents
Infection control
License/comply w/ fed/state/locl law/prof std
Quality of care
Alcohol based hand rub dispenser (abhr)
Cooking facilities
Corridors - construction of walls
Egress doors
Electrical equipment - testing and maintenanc
Exit signage
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke barrie
Inspection Report
Routine
Deficiencies: 3
Date: Dec 1, 2023
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident care, treatment, and facility safety.
Findings
The facility failed to ensure adequate personal hygiene care for a resident dependent on staff for shaving. It also failed to provide appropriate wound assessments and care plan updates for residents with pressure ulcers and skin concerns. Additionally, the facility did not comply with fire code requirements for carbon monoxide detection and maintenance.
Deficiencies (3)
F 0677: The facility did not ensure a resident dependent on staff for hygiene was offered or provided shaving after showering, violating the Activities of Daily Living policy.
F 0684: The facility failed to provide appropriate wound assessments and care plan revisions for two residents with pressure ulcers and skin damage, lacking documentation and timely communication.
F 0836: The facility did not comply with the 2020 Fire Code of New York State by failing to maintain carbon monoxide detectors in good working order, including lack of cleaning and preventative maintenance.
Report Facts
Residents reviewed for hygiene: 4
Residents reviewed for wound care: 7
Floors affected by carbon monoxide detector issues: 4
Monthly carbon monoxide detector tests documented: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in hygiene care deficiency related to Resident #166. |
| LPN #4 | Licensed Practical Nurse, Unit Manager | Named in hygiene care deficiency related to Resident #166. |
| Director of Nursing | Director of Nursing | Provided statements regarding hygiene care expectations and wound care oversight. |
| RN #1 | Registered Nurse, Unit Manager | Provided wound care documentation and observations for Resident #192. |
| LPN #7 | Licensed Practical Nurse | Documented wound care and provided interview statements regarding Resident #192. |
| LPN #1 | Licensed Practical Nurse | Provided wound care for Resident #31 and reported to supervisor. |
| LPN #9 | Licensed Practical Nurse, Unit Manager | Interviewed regarding wound care awareness for Resident #31. |
| LPN #10 | Licensed Practical Nurse, Unit Manager | Sent email to Nurse Practitioner about Resident #31's wound concerns. |
| Plant Operations Director | Plant Operations Director | Provided information about carbon monoxide detector maintenance and testing. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 30, 2023
Visit Reason
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Findings
One widespread standard health deficiency related to reporting to the national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Routine
Deficiencies: 2
Date: Oct 1, 2021
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulations related to resident care, including investigation of alleged abuse and appropriate use of psychotropic medications.
Findings
The facility failed to thoroughly investigate alleged facial bruising of unknown origin for Resident #138 and did not ensure gradual dose reductions or adequate justification for continued use of psychotropic medication Seroquel for the same resident.
Deficiencies (2)
F 0610: The facility did not have evidence that all alleged violations of abuse, mistreatment, and neglect were thoroughly investigated for Resident #138, specifically regarding facial bruising of unknown origin.
F 0758: The facility did not ensure residents using psychotropic drugs received gradual dose reductions or behavioral interventions unless contraindicated. Resident #138 was on Seroquel without adequate indication or documentation supporting increased dosage.
Report Facts
Medication dose: 50
Medication dose: 25
Behavior occurrences: 27
Behavior occurrences: 28
Behavior occurrences: 2
Behavior occurrences: 2
Behavior occurrences: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 Unit Manager | Registered Nurse Unit Manager | Noted bruising and documented physician notification for Resident #138; involved in medication management and behavior reporting |
| LPN #2 | Licensed Practical Nurse | Reported bruising to Nursing Supervisor for Resident #138 |
| LPN #3 | Nursing Supervisor | Responsible for investigation of bruising; ruled out abuse but failed to ensure investigation completion |
| Director of Nurses | Director of Nurses | Stated expectations for injury reporting and investigation; commented on medication use documentation |
| Consultant Pharmacist | Consultant Pharmacist | Discussed gradual dose reduction meeting and medication management for Resident #138 |
| Social Worker | Unit 1 A Social Worker | Reported Resident #138's mood and behaviors; discussed use of antipsychotics |
| LCSW | Licensed Certified Social Worker | Documented behavioral health consults and discharge of Resident #138 from counseling |
| Medical Director | Medical Director | Authorized increased Seroquel dose for Resident #138 and discussed medication rationale |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 18, 2019
Visit Reason
The inspection was conducted as a Standard survey to assess compliance with regulatory requirements related to resident transfer/discharge notifications and respiratory care.
Findings
The facility failed to provide timely written discharge notices to residents, their representatives, and the Ombudsman for two residents transferred to hospitals. Additionally, the facility did not maintain oxygen equipment properly for two residents requiring respiratory care, with soiled filters and unlabeled or undated oxygen tubing.
Deficiencies (2)
F 0623: The facility did not provide written discharge notices to residents, their representatives, and the Ombudsman for two residents transferred to hospitals as required by policy and regulation.
F 0695: The facility failed to provide safe and appropriate respiratory care for two residents by not cleaning oxygen concentrator filters and changing tubing as ordered, resulting in soiled filters and unlabeled or undated tubing.
Report Facts
Residents affected: 2
Residents affected: 2
Residents checked for oxygen tubing orders: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Discharge Planner | Stated she had not been giving discharge notices to residents or Ombudsman | |
| Social Worker (SW) | Oversaw unit and confirmed discharge letters were not sent to Ombudsman | |
| Licensed Practical Nurse (LPN #1) | Described oxygen equipment maintenance procedures | |
| Registered Nurse Unit Manager (RN UM #2) | Checked residents for oxygen tubing orders and described maintenance practices |
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