Chautauqua Nursing And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents’ personal money deposited with the nursing home was properly accounted for through quarterly statements and available receipts for withdrawals and Country Store purchases. The policy required residents or their representatives to receive at least quarterly accounting of financial transactions, with a separate receipt book maintained for withdrawals and receipts documenting the resident’s name, amount withdrawn, and purpose. Survey review found no evidence that quarterly statements were provided or sent to residents or their representatives for six reviewed residents, and there was no evidence of receipted accounting records for personal fund transactions from the facility’s store. Resident #18 had diagnoses including cerebral infarction, left-sided hemiplegia and hemiparesis, and aphasia, and the MDS documented moderate cognitive impairment. Resident #19 had leukemia, myelodysplastic syndrome, major depressive disorder, and generalized anxiety disorder, and was documented as cognitively intact. Resident #136 had COPD, polyosteoarthritis, and type 2 diabetes mellitus, and was cognitively intact. Resident #138 had left-sided hemiplegia and hemiparesis, epilepsy, and type 2 diabetes mellitus, and was cognitively intact. Resident #164 had rheumatoid arthritis, epilepsy, and major depressive disorder, and was cognitively intact. Resident #167 had paranoid schizophrenia, Alzheimer’s disease, and dementia, and was severely cognitively impaired. Review of their trust statements showed numerous Country Store transactions for each resident, but there was no evidence of receipts supporting those transactions. The Administrator provided a letter stating an internal review of resident trust accounting had found inconsistencies in how Country Store transactions were recorded and that spending activity dating back to 01/01/2024 would be reimbursed. A document stated quarterly statements were generated in 2024 and 2025, but it did not show that they were actually given or sent to residents or representatives. Interviews with the Business Office Manager, Administrator, Regional President, Social Worker, Medicaid Coordinator, Ombudsman, residents, and responsible parties confirmed that receipts were not kept, quarterly statements were not documented as sent, and the facility could not verify prior purchases. The Business Office Manager acknowledged there were no independent records, no receipt book, and no way to verify previous purchases, and the Administrator stated the records were poor and transactions had been entered based on memory rather than receipts.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report alleged abuse, neglect, mistreatment, or misappropriation of resident funds to the State Agency within the required timeframe after concerns arose about the Country Store transactions tied to multiple residents’ personal funds accounts. The deficiency involved six residents whose trust statements showed repeated store transactions over extended periods, including residents with moderate to severe cognitive impairment. The report states that the facility did not ensure all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source, were reported immediately or within 2 hours or 24 hours as required, depending on the circumstances. Review of the residents’ trust statements showed numerous documented transactions at the facility’s store for each of the six residents. The Ombudsman reported that families had recently received a letter from the facility about an audit going back to January 2024, and that residents were reimbursed for store purchases because the record keeping was not adequate. A family member of one resident questioned Country Store purchases, and the Administrator reviewed the transactions but could not find documentation related to them. The Business Office Manager stated there were no receipts for the transactions and acknowledged that receipts should have been kept. Interviews showed that the Business Office Manager had been recording Country Store transactions without receipts or activity order slips and was entering purchases based on memory. The Administrator stated the Business Office Manager did not keep receipts and was putting transactions into the system without documentation. The Regional President and Chief Human Resource Officer investigated after the issue was brought to their attention, and the Regional President stated they could not verify whether misappropriation had occurred because there were no receipts. Staff members described the repeated weekly purchase amounts as suspicious and said the pattern raised concerns about possible financial abuse, especially for residents with lower cognitive scores and limited family involvement. Despite these concerns, the facility did not report the matter to the State Agency as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Survey findings identified that the Administrator did not provide adequate oversight of the Business Office Manager to ensure adequate accounting and records of personal funds. The facility policy stated that residents who manage their personal financial affairs are to receive at least quarterly accountings, that a separate receipt book is to be maintained for withdrawals, and that receipts should document the resident’s name, amount withdrawn, purpose, and signature of the resident or power of attorney. The survey also found that when there was reasonable suspicion of misappropriation of resident funds, it was not reported to the State Agency within the required timeframe. The facility’s incident and abuse reporting policy stated that personnel must report suspected incidents immediately and that allegations of abuse, neglect, mistreatment, or misappropriation must be reported as soon as possible, not to exceed two hours. During interviews, the Administrator stated that Business Office Manager #1 was responsible for quarterly statements and maintaining receipts from the Country Store, and that the Administrator or DON was responsible for reporting suspicions of abuse to the State Agency. The Regional President stated the Administrator oversaw Business Office Manager #1 and would notify them whenever something should have been reported to the State Agency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure treatment and care were provided in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident with diabetes mellitus, left-sided hemiplegia, and a history of transient ischemic attack. The resident was cognitively intact and had care plan interventions to check skin and feet with daily care, document weekly on shower day, and monitor skin daily because of anticoagulant therapy. The facility policy required skin findings to be reported to the unit manager/supervisor, with nursing status documentation, provider notification, and orders for appropriate treatment. During observation, the resident was found with edema, ecchymosis, and a skin injury on the right shin measuring approximately one inch long by one-half inch wide. The resident stated they were on anticoagulants and had scraped the leg on the bed frame. The resident later stated the injury was not reported because it had stopped bleeding and no staff had asked or assessed the shin. A CNA stated they noticed the injury during a shower, saw that it was scabbed over, and did not report it. The CNA stated skin issues should be reported because the injury could have reopened and caused an infection. An LPN stated they had not been notified of the injury and that staff should have immediately reported it so a skin assessment, provider notification, and investigation could be initiated. The DON stated CNAs were trained to notify the nurse whenever they observed a skin issue and that skin checks should be completed daily during morning care and on shower days.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Appropriate care was not provided for a resident with a suprapubic Foley catheter when the gravity drainage bag was left hanging on the left armrest of the wheelchair above the level of the bladder. Resident #10 had diagnoses including urinary tract infection, urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms, chronic kidney disease stage 3B, neurogenic bladder, and Parkinson’s disease, and the resident was cognitively intact but required maximal assistance for toileting-related care. The care plan identified the resident as at risk for infection and documented the suprapubic catheter with infection control precautions. During observation, the resident was sitting in a wheelchair next to the bed, and the catheter drainage bag remained on the armrest and was about 25 percent full of urine, unable to drain by gravity. The resident stated they did not realize the bag was on the wheelchair arm and could not move it themselves. The CNA responsible for the resident stated the bag had been hooked on the armrest before transfer and was forgotten afterward, and acknowledged it should have been placed under the wheelchair so urine could not flow back into the bladder. Nursing staff, the unit manager, the infection preventionist, and the medical director all stated the drainage bag should always be kept below the level of the bladder to allow drainage and prevent backflow.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Routine inspection, maintenance, and safe functioning of bed frames and mattresses were not ensured for one resident. Resident #7 had diagnoses of diabetes, left-sided hemiplegia, and a history of transient ischemic attack, and was cognitively intact per the MDS dated 02/07/2026. The facility’s maintenance policy stated that resident-related medical equipment would be inspected per manufacturer policy and preventative maintenance scheduled based on manufacturer recommendations, and the bed manual directed periodic inspection of the bed system, including the mattress and components, to reduce the risk of entrapment. The facility’s Resident Entrapment Assessment binder showed routine bed assessments were documented only through June 2023, with no evidence of ongoing audits or follow-up. During observations, Resident #7’s mattress was repeatedly found too small for the bed frame and not secured in place. Six inches of exposed metal frame were seen along the outside parameter of the bed, and no mattress retainer bars were present, despite the manufacturer’s specifications indicating that mattress retainers were included with the bed and were to keep the mattress from sliding. The mattress slid back and extended beyond the bed frame, and the resident stated the mattress never stayed in place. Staff interviews showed the unsafe condition had not been reported to nursing or maintenance when first noticed, and the DON and maintenance leadership acknowledged that routine bed audits had not been completed since June 2023.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper consultation with a resident's physician when there was a significant need to alter treatment, specifically regarding the administration of the medication Nuplazid. The resident, who was cognitively intact and had a history of falls and behavioral issues, was prescribed Nuplazid to manage behaviors such as crawling on the floor and aggression towards staff. However, due to insurance constraints, the medication required reordering every 14 days, which the facility failed to manage effectively, resulting in 20 missed doses over two separate periods. The facility's policy required immediate notification of the nursing supervisor and the medical provider when medications were not available, but this protocol was not followed. The nursing staff did not inform the resident's physician about the missed doses or the need to reorder the medication, leading to a lapse in treatment. Interviews with staff revealed that there was a lack of a systematic approach to ensure timely reordering of the medication, and during a transition period between unit managers, the responsibility for reordering was not adequately managed. The resident's neurologist/psychiatrist and the facility's medical director both expressed that they should have been informed of the medication lapse. The consultant pharmacist noted that stopping Nuplazid abruptly could lead to the reemergence of behaviors and hallucinations. The facility's failure to adhere to its protocols for medication management and physician notification resulted in a significant deficiency in the resident's care.

Plan Of Correction

Plan of Correction: Approved March 27, 2025 1. Resident #1 was assessed for 5 consecutive days and reviewed with the Medical Director and determined to have no current negative outcomes. Care plan was reviewed and in concert with the resident’s needs. Medication error report was completed and shared with the IDT member, physician, pharm consultant and dispensing pharmacy. Consultant ordering Psychiatrist was updated on the omission and a follow up visit was provided/pending. 2. All residents experiencing changes in conditions or falls have the potential to be affected by this deficient practice. The DON conducted a review of all residents currently in the facility experiencing changes in condition, medications not being administered as ordered and falls to determine physician notifications were completed. No other deficiencies were found. 3. Measures that were put in place to ensure the deficient practice does not recur. The Unit Manager was educated on the policies titled Medication/Treatment Administration Documentation and Change in Resident's Condition, Medication/Treatment or status. The DON will conduct an audit of 10 residents a week with falls and/or a change in medical conditions to determine notification to the physician until 100% compliance for 4 consecutive weeks is sustained. Included in the audit will be a review to determine that the medical provider was notified of missed medication doses. The policies were reviewed and no changes were necessary. All staff responsible for Medication Administration Documentation were educated on the policy titled Medication/Treatment Administration Documentation. All staff responsible for Physician notifications and family notifications regarding changes of care and resident condition were educated on the policy titled Change in Resident's Condition, Medication/Treatment or status. The facility reviewed all orders with 14 day renewals on the MAR / TAR and changed the orders to standing orders so the order will not fall off. The Pharmacy will send reminders if additional authorization is needed prior to filling the medication. 4. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be immediately counseled. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 5. Corrective action will be completed by 05/18/2025. The Director of Nursing Services is responsible for implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that pharmaceutical services met the needs of a resident, specifically in the acquisition and administration of the antipsychotic medication Nuplazid. The resident, who was cognitively intact and had a history of falls, paranoid thoughts, and hallucinations, was prescribed Nuplazid to manage these symptoms. However, the medication was not administered for 20 doses due to lapses in reordering, which was required every 14 days per insurance policy. The facility's policy required that medication discrepancies be reported and addressed, but no medication error reports were completed for the missed doses. The deficiency occurred because the Licensed Practical Nurse (LPN) Unit Manager was unaware of the need to physically write a new order every 14 days for the medication, mistakenly believing it could be reordered like other medications. This misunderstanding led to periods where the medication was not administered, contributing to the resident's behavioral issues, such as refusing care and placing themselves on the floor. The facility's interim Director of Nursing acknowledged that the medication required a new prescription every 14 days and that the cart nurses were responsible for alerting unit managers when the medication was running low. Interviews with the Neurologist/Psychiatrist and the Consultant Pharmacist highlighted the importance of Nuplazid for the resident's mental health and the risks associated with abruptly stopping the medication. The facility's failure to reorder and administer the medication as prescribed resulted in the resident not receiving the necessary treatment to manage their condition. The Medical Director emphasized the facility's responsibility to ensure residents receive their medications as ordered and to notify the physician if there are any lapses in administration.

Plan Of Correction

Plan of Correction: Approved March 27, 2025 1. Resident #1 had an immediate review of his Medication Administration Record [REDACTED]. Resident was assessed and monitored for 5 consecutive days to monitor for adverse effects. None were noted. MD was notified regarding medication omission. Medication error report was completed and shared with the IDT member, pharm consultant and dispensing pharmacy. Resident’s care plan was reviewed and in concert with residents current needs. A reminder was added to the DON, ADON and Unit Managers calendars every 14 days for Res #1's Nuplazid renewal. An additional order was entered to reorder the medication every 14 days to trigger the medication nurse to ensure medication is reordered timely. 2. All residents on 14 day renewal medications, with medications that have special medication ordering needs or medications requiring a new script have the potential to be affected by this deficient practice. The facility reviewed all other residents to ensure there were no other special medication ordering needs. None were identified. The DON conducted a full house audit of all residents on medications requiring a new script or preauthorization and no other issues were found. The facility changed all orders with 14 day renewals on the MAR / TAR to be entered as standing orders so that a new script is not required each time so this problem does not recur. The pharmacy will notify the facility if a preauthorization is needed. 3. The Unit Manager was educated on the Ordering Medications/Treatments from Pharmacy policy and the Medication/Treatment Discrepancy/Error policy. The policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error were reviewed and no changes were necessary. 4. Measures that were put in place to assure the deficient practice does not recur: - All staff responsible for Medication / Treatment Administration were educated on the policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error. - The DON will conduct weekly audits of the resident population with 14 day renewals to ensure orders are present. All current and new 14 day renewal orders will be audited weekly until 100% compliance is sustained x 4 weeks. If 100% compliance is not found, the staff involved will be counseled immediately. 5. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 6. The Director of Nursing will be responsible for monitoring compliance of the corrective plan with the facility administrator having overall responsibility for the conduct of the plan. Corrective action will be completed by 05/18/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident, leading to a fall. The resident, who had diagnoses including hemiplegia, hemiparesis, malignant neoplasm of the brain, and vascular dementia, was cognitively intact and understood instructions. The comprehensive care plan indicated that the resident was at risk for falls due to cognition, mobility, and right-sided weakness, requiring supervision while on the toilet and a sit-to-stand lift with two-person assistance for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) assisted the resident onto the toilet using the sit-to-stand lift but left the resident alone in the bathroom, contrary to the care plan's requirement for supervision. The CNA was unaware of the care plan intervention requiring supervision and admitted to not checking care plans often. As a result, the resident attempted to reach for a urinal, unhooked the lift belt, and fell, sustaining a bruise to the head and experiencing hip and knee pain. Interviews with staff revealed that the expectation was for CNAs to check the Kardex daily, but the CNA involved did not adhere to this practice. The Director of Nursing and other staff emphasized the importance of following care plans to prevent accidents and injuries. The incident highlighted a break in the care plan, which was not followed, leading to the resident's fall and subsequent injuries.