Wells Rehabilitation and Nursing Center

Based on record review and interviews during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for 2 of 3 residents reviewed. Specifically, the facility did not ensure 2 (Residents #141 and #142) who received Medicare Part A services, received timely notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC. This is evidenced by: There was no documented evidence that residents #141 and #142 received 2-day notification prior to the termination of rehabilitative services. During an interview on 9/06/2024 at 11:34 AM, Fiscal Clerk #1 stated that they could not account as to why residents #141 and #142 did not receive a 2-day notification prior to the termination of Medicare services. During an interview on 9/06/2024 at 11:37 AM, Administrator #1 stated that the Fiscal Clerk would be re-educated on the 2-day notification. 10 New York Codes, Rules and Regulations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, opened medications had no open and/or expiration dates for 1 (2nd floor medication cart) of 2 medication carts reviewed. This is evidenced by: The facility's Medication Storage and Expiration of Medications policy revised on 6/2018 documented, once any medication or biological product was opened, follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Record the date opened on the medication container when the medication had a shortened expiration date once opened. Record calculated expiration date based on date opened on the medication container. The facility's Medication Administration Procedures policy dated 9/2024 documented to not give a medication if the label was unclear or illegible. During an observation on [DATE] at 12:10 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer and equipment required cleaning. This is evidenced as follows. The kitchen was inspected on 10/21/2021 at 10:36 AM. The concentration of QAC used to sanitize food contact equipment was found to be 150 parts per million (ppm) when measured at 71 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 200 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The refrigerator shelving and door gaskets in the 1st floor nourishment area were soiled with food particles. Record review of the education given to dietary employees revealed that it did not provide specifics on how to check the QAC concentration and to clean refrigerator door gaskets. The Food Service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during a recertification survey the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of quality of life for 1 (Unit 2) of 2 resident dining rooms and 4 (Resident #'s 2, 4, 70, and #73) of 5 residents reviewed for dignity. Specifically, the facility did not ensure staff were interacting with residents rather than with each other while assisting residents with meals in 1 of 2 dining rooms; Specifically, for Resident #2, the facility did not ensure the resident's pants were not urine soaked, that a puddle of liquid was not beneath the resident's chair and feet, and that the odor of urine did not permeate a public area of the unit where the resident was observed sitting in a recliner chair; for Resident # 4, the facility did not ensure the resident's right to privacy was protected in the resident dining room; for Resident # 70, the facility did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for five Residents (# 33, 42, 70, & 91) of 22. Specifically: for Resident #33, the facility did not ensure that that her care plan for toileting was implemented and addressed the fact that she was continent, that Resident #42 had a care plan to address the different types of pain, that Resident # 70 &91's care plans for pain had interventions individualized for those residents . This is evidenced by: Resident #42: The resident was admitted to the facility on [DATE], with the diagnosis of polyneuropathy, low back pain with spinal stenosis and Parkinson's Disease. The Minimum Data Set (MDS) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan (CCP), and the residents' goals and preferences, for three (Resident #'s 42, 70, and #91) of seven reviewed for pain. Specifically, for Resident #42, 70, and #91, the facility did not ensure that the resident's received adequate pain management. This is evidenced by: The Policy & Procedure titled Pain Management dated 8/2018 documented, it is the policy of the Nursing Home to provide adequate pain management to keep the residents as comfortable as possible. Each Resident each shift and with each pain medication pass will be asked to rate his/her pain according to the MDS pain rating scale. The response will be documented on the electronic Medication Administration Record (eMAR). Documentation for routine pain management needs to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy for bringing food(s) in from outside of the facility included a process for assisting residents in accessing and consuming the food if a resident is unable to do so on his/her own and the facility did not provide information for family and visitors on safe food preparation and handling practices. This will be evidenced by: A Policy and Procedure (P&P) titled Bringing Food(s) in From Outside the Facility dated 10/2017, documented foods brought in by family memberes or guests will be reported to the Charge Nurse, who would notify Food and Nutrition Services (Diet Technician or responsible staff) for these foods to be received, appropriately stored, and added to the resident's daily menu if appropriate. The food would be stored in the kitchen with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during a recertification survey and an abbreviated survey (Case #NY00238270) the facility did not ensure the resident's physician was consulted when there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 (Resident #42) of 1 resident reviewed for infections. Specifically, for Resident #42, the facility did not ensure the physician was notified that the resident, with a recent history of Clostridium difficile (C-diff) (a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon), was having frequent episodes of loose stools and rectal irritation. This is evidenced by: Resident #42: The resident was admitted to the facility on [DATE], with the diagnoses of polyneuropathy, Parkinson's Disease,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews during a recertification survey, the facility did not ensure the residents and/or resident representatives were provided with specific notification when the facility determined that the residents no longer qualified for Medicare Part A services and Medicare benefit days remained for 3 of 3 residents reviewed for Beneficiary Protection Notification. Specifically, for Resident #'s 59, 293, and #294, the facility did not ensure the residents or resident representatives were informed of the beneficiary's potential liability for payment and related standard claim appeal rights using the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form CMS-10055. This is evidenced by: The facility was unable to provided documentation that the SNFABN was issued to the identified residents or the resident representatives. During an interview on 5/09/19 at 11:12 AM, Accounts Receivable #10 stated she was unable to find documentation that the SNFABN was issued for the identified residents. She stated she was not familiar with the SNFABN form and it had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews during a recertification survey the facility did not ensure that it addressed the resident's goals of care and treatment preferences. If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose, and update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities, for one (Resident #22) of two residents reviewed for discharge to the community. Specifically, for Resident #22, the facility did not ensure a referral was made to the appropriate entities when the resident stated she wanted to go home. This is evidenced by: Resident #22: The resident was admitted to the nursing home on 4/20/18, with diagnoses of muscle weakness, Urinary Tract Infection (UTI), lymphedema, glaucoma, hypertension (HTN), peripheral vascular disease (PVD).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for 2 residents (Residents #59 and Resident #70) of 2 residents reviewed. Specifically: For Resident #59 and 70, the facility did not ensure a physician's order and indication for use was obtained for the administration of oxygen. This is evidenced by: The Facility Policy and Procedure (P&P) titled Physicians Routine Standing Orders, dated 2/2018, documented a Procedure for Limited Use Respiratory Standing Order for; Oxygen (02) 2-3 Liters (L) as needed (PRN) vial nasal cannula (NC) up to 5L/minute (min) PRN via mask. The Facility Policy and Procedure (P&P) titled Oxygen by Concentrator, dated 12/2013, documented a general instruction to adjust liter flow as ordered by the physician. Resident #59: The resident was admitted to the facility on [DATE], with a diagnosis of congestive heart failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Chemicals used in food equipment sanitizing are to be at the correct concentration, food contact surfaces are to be cleaned after use, and non-food contact surfaces must be kept clean. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer, food contact equipment required cleaning, and non-food contact equipment was not clean. This is evidenced as follows. The kitchen was inspected on 05/06/2019 at 8:45 AM. The concentration of QAC used in the sanitizing rinse sink, and the third sink, was found to be at 0 parts per million (ppm) when measured at 70 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The cutting boards on the storage rack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in an area with gas fuel fired equipment. This is evidenced as follows. Observations on 05/07/2019 at 1:55 PM, revealed a fuel burning appliance in the kitchen and laundry rooms without a carbon monoxide detection device. The Plant Operations Director stated in an interview on 05/07/2019 at 2:05 PM, that he was unaware that it was a requirement to provide carbon monoxide detection in these areas. 483.70 (b); 2015 International Fire Code, Section 915

Based on record review, and interviews during the recertification survey, the facility did not ensure training was provided to their staff on dementia management and resident abuse prevention. Specifically, the facility did not ensure staff were educated on factors related to dementia care and abuse prevention, including conflict resolution, anger management skills, and identifying and addressing staff burnout, frustration, and stress. This is evidenced by: Review of an undated in-service titled Caring for Residents with Dementia provided by Registered Nurse (RN) #7 did not include information related to conflict resolution between staff and residents, visitor and resident, and resident to resident conflicts, anger management, and identifying and addressing staff burnout, frustration, and stress in staff. During an interview on 5/09/19 at 10:23 AM, RN #6 was not able to provide documentation that facility staff had received been educated on resolving conflicts, anger management skills, and identifying and addressing staff burnout, frustration, and stress in staff prior to survey…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.