Wellsville Manor Care Center

Based on observations, interviews, and record review conducted during a Standard survey completed on 6/14/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #58) of three residents reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #58's right hand splint was worn at all times as ordered and care planned. The finding is: The policy and procedures titled Assistive Devices and Equipment, revised on 1/2024, documented that devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to wheelchairs (manual and powered), walkers, canes, adaptive devices etc. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. Resident #58 had diagnoses of cellulitis (a bacterial skin infection), urinary tract infection, and adult…

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 interview and record review conducted during a Standard survey completed 6/14/24, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services or other clinically qualified nutrition professional. The finding is: The policy and procedure titled Food and Nutrition Services revised 1/2024 did not include qualifications and skills sets for clinically qualified nutrition professionals. Review of the undated job description job title Nutrition Service Director revealed the candidate must provide documentation of registry/certificate upon application for the position, must have training in cost control, food management, and diet therapy. Review of the undated job description job title Diet Tech revealed the purpose of the job position is to oversee nutritional well-being of residents by conducting nutrition…

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, interview and record review conducted during a Standard survey completed 6/14/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for one (Resident #307) of two residents reviewed for infection control practices during pressure ulcer care. Specifically, staff did not maintain proper hand hygiene during wound care and the resident was not on enhanced barrier precautions (infection control interventions including gown and glove use for high contact resident care activities designed to reduce transmission of multidrug-resistant organisms). The finding is: Review of the policy and procedure titled Hand Washing/hygiene dated 1/24 documented that all personal should follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors. The use of alcohol-based hand rub or soap and water should be used for the following situations: before handling clean or soiled dressings, gauze…

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 interview and record review conducted during an Abbreviated survey (Complaint #NY00338118) the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse, to the facility's Administrator and the State Survey Agency for one (Resident #1) of three residents reviewed. Specifically, facility staff did not report an allegation of abuse/mistreatment of a resident to the Director of Nursing or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State Department of Health as required. The finding is: The policy and procedure titled Abuse and Neglect last reviewed/revised: 4/2024 documented the Administrator and Director of Nursing will be immediately informed of any alleged or suspected occurrence of abuse or neglect. The Administrator or designee will provide a 2-hour notification to the New York State Department of…

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 interview and record review completed during the Standard survey conducted 7/18/22 through 7/22/22, the facility did not ensure the providers made actual face to face contact with the residents at required visits for 3 of 9 residents (Resident #s 314, 55, and 82) reviewed. Specifically, provider visits were completed via telehealth (delivery of health care via remote technologies) and not in person (face to face) as required. The findings are: The policy and procedure (P&P) titled Provider Visits with a revised date of 1/22 documented the attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The P&P documented the NP (nurse practitioner) may preform required visits by state and federal regulations. Review of a hand written note provided by the Director of…

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 interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees #4, 5, 6, 7) of eight employees who were subject to the New York State (NYS) Nurse Aide Registry had not been screened through the NYS Nurse Aide Registry prior to their employment. The findings are: Review of the facility policy titled Employee Files dated 11/2016, revealed all applicants, for all departments, must be screened through Prometric (outside contractor that maintains the NYS Nurse Aide Registry) to confirm if the person in question has ever worked as a Certified Nurse Aide (CNA) and/or ever had any disciplinary actions enforced. A copy of the findings to be reviewed for status and placed in the permanent file. 1. Review of Employee #4's (Human Resources (HR) Coordinator) personnel file…

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, interview and record review conducted during the Standard survey completed 8/2/19, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan for one (Resident #46) of one resident reviewed for dialysis. Specifically, there was no collaboration between the facility and the dialysis center regarding removal of the dialysis dressing post dialysis. The finding is: Review of the facility policy and procedure titled Hemodialysis Documentation with a revision date 5/4/11 revealed under Shunt Care to monitor for bruit (whooshing sound of blood flow) and thrill (a buzzing vibration felt by palpitation) each shift and record in the Medication Administration Record/Treatment Administration Record (MAR/TAR), blood pressure (B/P) readings and blood specimens should not be drawn from the arm with the shunt. Between dialysis treatment, the skin over the internal AV (arteriovenous)…

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, interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure that residents who have not used anti-psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use anti-psychotropic drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs for one (Resident #75) of five residents reviewed for anti-psychotropic medications. Specifically, there was a lack of behavior documentation that warranted the administration of an antipsychotic medication (Abilify) and a lack of behavior documentation addressing the positive/negative effects of the antipsychotic on the resident. Additionally, there was a delay in acting upon recommendations for a GDR. The finding is: Review of a facility policy titled Antipsychotic Medication Policy dated 2/2018…

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.