Inspection Reports for
Chautauqua Nursing and Rehabilitation Center
10836 Temple Road, Dunkirk, NY, 14048
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Inspection Report — Mar 27, 2026
Certification/complaint State
Date: Mar 27, 2026
Visit Reason
State-compiled facility profile showing 19 inspections from 2022 to 2026 with citation and complaint history.
Complaint Details
The state logged 81 complaints about this facility; 14 led to on-site inspections. Three citations resulted from those complaints.
Findings
Across 19 inspections, 42 citations were issued, including 22 standard health and 20 Life Safety Code citations. Most citations were minor potential harm (Level 2), with no formal enforcement actions recorded.
Citations (37)
Standard Health Citation — quality of care: Accounting And Records Of Personal Funds had widespread Level 2 minor potential harm issues corrected by May 26, 2026.
Standard Health Citation — quality of care: Administration had widespread Level 2 minor potential harm issues corrected by May 26, 2026.
Standard Health Citation — quality of care: Bowel/bladder Incontinence, Catheter, Uti had isolated Level 2 minor potential harm issues corrected by May 26, 2026.
Standard Health Citation — quality of care: Department Criminal History Review had isolated Level 0 no harm potential issues corrected by May 26, 2026.
Standard Health Citation — quality of care: Quality Of Care had isolated Level 2 minor potential harm issues corrected by May 26, 2026.
Standard Health Citation — quality of care: Reporting Of Alleged Violations had widespread Level 2 minor potential harm issues corrected by May 26, 2026.
Standard Health Citation — quality of care: Resident Bed had isolated Level 2 minor potential harm issues corrected by May 26, 2026.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notif had isolated Level 0 no harm potential issues corrected by May 26, 2026.
Life Safety Code Citation — NFPA requirements: Alcohol Based Hand Rub Dispenser (abhr) had pattern Level 2 minor potential harm issues corrected by May 26, 2026.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System had pattern Level 2 minor potential harm issues corrected by May 26, 2026.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Other had pattern Level 2 minor potential harm issues corrected by May 26, 2026.
Life Safety Code Citation — NFPA requirements: Elevators had pattern Level 2 minor potential harm issues corrected by May 28, 2026.
Life Safety Code Citation — NFPA requirements: Exit Signage had pattern Level 2 minor potential harm issues corrected by May 26, 2026.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure had pattern Level 2 minor potential harm issues not yet corrected.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers had pattern Level 2 minor potential harm issues corrected by May 26, 2026.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing had pattern Level 2 minor potential harm issues corrected by May 26, 2026.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures had pattern Level 2 minor potential harm issues not yet corrected.
Standard Health Citation — quality of care: Notify Of Changes (injury/decline/room, Etc.) had isolated Level 2 minor potential harm issues corrected by May 3, 2025.
Standard Health Citation — quality of care: Pharmacy Srvcs/procedures/pharmacist/records had isolated Level 2 minor potential harm issues corrected by May 3, 2025.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices had isolated Level 2 minor potential harm issues corrected by September 24, 2024.
Standard Health Citation — quality of care: Reporting - National Health Safety Network had widespread Level 2 minor potential harm issues not yet corrected (multiple COVID19 surveys from Dec 2023 to Jan 2024).
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents had isolated Level 2 minor potential harm issues corrected by January 30, 2024.
Standard Health Citation — quality of care: Infection Control had isolated Level 0 no harm potential issues corrected by January 30, 2024.
Standard Health Citation — quality of care: License/comply W/ Fed/state/locl Law/prof Std had widespread Level 1 potential for minimal harm issues corrected by January 30, 2024.
Standard Health Citation — quality of care: Quality Of Care had isolated Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Alcohol Based Hand Rub Dispenser (abhr) had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Cooking Facilities had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Corridors - Construction Of Walls had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Egress Doors had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenanc had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Exit Signage had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storag had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie had pattern Level 2 minor potential harm issues corrected by January 30, 2024.
Standard Health Citation — quality of care: Reporting - National Health Safety Network had widespread Level 2 minor potential harm issues not yet corrected on May 30, 2023.
Report Facts
Inspections on page: 19
Total violations/deficiencies cited: 42
Inspections with violations: 11
Inspections without violations: 8
Total complaints: 81
On-site complaint inspections: 14
Citations from complaints: 3
Total standard health citations: 22
Total Life Safety Code citations: 20
Citations by category - Administration: 2
Citations by category - Other Services: 2
Citations by category - Physical Environment: 1
Citations by category - Quality of Care: 4
Citations by category - Resident Rights: 2
Inspection Report — Mar 5, 2025
Complaint Investigation CMS
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.
Citations (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 — Aug 12, 2024
Abbreviated Survey CMS
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.
Citations (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 — Dec 1, 2023
Routine CMS
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.
Citations (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 — Oct 1, 2021
Routine CMS
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.
Citations (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 — Jan 18, 2019
Routine CMS
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.
Citations (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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