Owensboro, KY – Nursing Home Cited with Multiple Violations

Nursing home cited with multiple violations By James Mayse Messenger-Inquirer Apr 12, 2022

An Owensboro nursing home was fined nearly $100,000 in August, after a federal agency found the facility hadn’t done enough to protect residents from aggressive patients.

Chautauqua Health and Rehabilitation, 1205 Leitchfield Road, was fined $99,967 in August, after an investigation by the Centers for Medicare and Medicaid Servies. The agency is part of the Department of Health and Human Services.

The full report can be found on the Medicare.gov website OR visit NHAA and see their full history here: https://nursinghomesabuseadvocate.com/nursing-homes/chautauqua-health-and-rehabilitation/

A summary of the report says investigators cited the facility for five instances of “freedom of abuse, neglect and exploitation deficiencies,” seven “quality of life and care deficiencies,” and two resident rights deficiencies.

In particular, the August report says investigators found the facility received a “5” on a 1-5 harm scale, determining the facility had failed to “timely report suspected abuse, neglect or theft and report the results to the proper authorities;” failed to “protect each resident from all types of abuse, such as physical, mental, sexual abuse, physical punishment and neglect by anybody;” and had failed to “respond appropriately to all alleged violations.”

The report says the violations were corrected by November, through staff training. Officials with the facility, and with the facility’s owners and management, did not return multiple calls.

The investigation was conducted by interviewing nursing home staff members. The report only identified residents by number, but documents several instances where a resident verbally harassed others, issued threats and made sexually inappropriate gestures, and where a second resident caused two residents to fall, where one suffered a broken thigh bone.

The report documents incidents with going back to March 26 of last year. The report documents incidents where “Resident 6” yelled at, cursed or threatened other residents, but also includes reports of the resident kicking, exposing themselves, throwing things, engaging in appropriate sexual acts in public and threatening to kill other residents.

The report say there were more than 20 incidents documented involving Resident 6 between March and August.

In an interview, one staff member said, “It was just a matter of time before the resident hurt another resident.”

The staff member said the facility’s administration was aware of the residents aggressive behavior. The report says in many of the complaints, “there was no evidence provided that this incident was investigated.”

A second resident, “Resident 85,” had incidents of “physical or verbal altercations with other residents” in May, June and July of last year. The report says Resident 85 was observed by staff grabbing another resident by the shirt on Aug. 21. As the victim attempted to pull way, the resident let go, causing the victim to fall. That resident did not suffer an injury. Resident 85 was taken to his room, the report says.

The next day, Aug. 22, Resident 85 pushed another resident down, and the victim suffered a fracture femur which required surgery.

Nursing assistants who were interviewed after the incident told investigators the Resident 85 “usually got into an altercation with another resident at least one of (every) three days” the CNAs were working.

Another staff member told investigators he had seen the resident “trying to push other residents down, grabbing other residents, and grabbing other residents’ food and drink. The staff member said the director of nursing had been told about the incidents, “but nothing had been done.”

The director of nursing, who was interviewed more than once after the Aug. 22 incident where the victim suffered a fractured femur, said “she was unaware of Resident 85’s history of aggression toward other residents,” and that interventions should have put in place after Aug. 21. The director of nursing also aid she was unsure interventions would have prevented the incident the next day.

After the Aug. 22 incident, the Resident 85 was put on 15-minute checks, the report says.

The administrative staff all underwent education on how to identify and prevent abuse, and when to report it, on Aug. 26. Other staff members were prohibited from working before also undergoing abuse education.

Interventions and care plans “for all residents with behaviors affecting others” were put in place on Aug. 27, the report says.

Chautauqua Health and Rehabilitation was formerly known as Owensboro Place Care and Rehabilitation. The facility is managed by Clearview Healthcare Management of Kentucky and owned by Owensboro OPCO KY LLC, which has a New Jersey address.

Officials from Chautauqua Health did not return a call made two weeks ago, or a call made Monday. The person who answered the phone at Clearview Healthcare Monday said the COO was out of town and not available. A previous call to Clearview was not returned.

The New Jersey address is for the Portopiccolo Group. The company could not be reached for comment Monday.

The facility has been fined previously. The facility was fined $608,228 in March, 2019, after a resident choked on eggs and died after being removed from life support.

The investigation found that some staff knew the resident was at risk of choking due to having a cognitive issue and needed assistance and observation while dining, but found other staff members were unaware there was an issue.

The report says when the resident was found unresponsive, a nurse began chest compressions. The reports said there was no documentation of trying to ventilate the resident. A paramedic responding to the 911 call removed a large piece of egg from the resident’s windpipe, the report says.

A review of the facilities emergency cart after the incident found the cart did not have a suction machine. A staff member who responded to the emergency said the suction machine was not assembled and she had to look through different drawers on the cart to find the parts, the report says.

TO THE OWENSBORO KENTUCKY COMMUNITY

CONTACT US HERE AT NHAA IF YOU HAVE ANY INFORMATION ON THE FORMER OWNERS OF THIS NURSING HOME PROVIDING POOR CARE FOR YOUR LOVED ONES.

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