Chautauqua Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Chautauqua Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 27, 2021

  Based on interviews, record reviews and facility policy review, it was determined that the facility failed to protect residents from physical, sexual, and verbal abuse for five (5) (Residents #35, #8, #58, #54, and #87) of five (5) sampled residents reviewed for abuse by Resident #85 and Resident #6. Specifically, Resident #85 knocked down Resident #35 down on 08/21/2021, and knocked Resident #8 down on 08/22/2021, resulting in a femur fracture. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed himself/herself, sexually during an activity, to Resident #58 and Resident #87. Staff reported that when Resident #6 came into the common area, other residents left due to the resident's behaviors. […]

• Immediate jeopardy, patternF609Aug 27, 2021

  Based on interviews, record reviews, and facility policy review, it was determined the facility failed to report abuse allegations and injuries of unknown origin to the State Survey Agency for six (6) (Residents #35, #8, #58, #54, #83, and #87) out of six (6) residents reviewed for abuse. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not reported. Resident #85 had physical or verbal altercations with other residents and the incidents were not reported. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a [CONDITION(S)]. […]

• Immediate jeopardy, patternF610Aug 27, 2021

  Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to investigate abuse allegations for six (6) (Residents #35, #8, #58, #54, #87 and #83) out of six (6) residents reviewed for abuse by Resident #85 and Resident #6. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not investigated. Resident #85 had physical or verbal altercations with other residents and the incidents were not investigated. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a [CONDITION(S)]. […]

• Immediate jeopardy, isolatedF740Aug 27, 2021

  Based on interviews, record reviews and reviews of the facility's policies, it was determined the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This deficient practice affected one (1) (Resident #6) of six (6) sampled residents reviewed for behaviors. Specifically, Resident #6 displayed behaviors directed toward other residents, and no new interventions were implemented to address behaviors. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed self sexually during an activity. […]

• No harm, potential for more than minimal, widespreadF812May 8, 2026

  Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety which had the potential to affect all residents who consumed meals from the kitchen. The findings include:1). Review of the facility's policy titled, Food Storage, dated 10/2019, revealed the Dietary Manager was to ensure all food items were stored properly in covered containers. Further review revealed the containers were to be labeled, dated, and arranged in a manner to prevent cross-contamination.Observation of the kitchen, on 05/05/2026 at 11:05 AM, revealed a dessert cart with 20 cups of chocolate trifle stored uncovered and undated in the freezer. […]