Wells Rehabilitation and Nursing Center

Inspectors wroteBased on observations, record review, and interviews during a survey, the facility failed to ensure residents were free from abuse for one (1) (Resident #1) of three (3) residents reviewed for abuse. On 02/04/2026, Resident #1 became combative during a shower, striking Certified Nurse Aide #2. Certified Nurse Aides #1 and #2 continued to provide shower care. Certified Nurse Aide #1 stated they continued the care and tried to deflect some of the blows toward Certified Nurse Aide #2. Resident #1 sustained injuries including skin tears, scattered bruising to right arm, hematoma (a localized collection of clotted or partially clotted blood outside blood vessels, often resulting from injury or trauma) on the back of head, a head laceration (cut), and a bruised left ankle. This resulted in actual harm of Resident #1 that is not Immediate Jeopardy and is past non-compliance. [...]

Inspectors wroteBased on record review and interviews during the recertification and abbreviated survey (Case #NY00338006), the facility did not ensure the resident's right to be free from neglect for 1 (Resident #48) of 18 residents reviewed for abuse and neglect. Specifically, on 4/03/2024, Certified Nurse Aide #2 did not use two-person assist for bed mobility as required in Resident #48's Comprehensive Care Plan while providing care to the resident. Resident #48 rolled out of bed onto the floor. Resident #48 sustained a pelvis fracture (a break of the bony structure of the pelvis). This resulted in actual harm that was not immediate jeopardy. This is evidenced by: Resident #48 was admitted with diagnoses of pulmonary edema (fluid collection in the chest cavity causing breathing difficulty), legal blindness, and chronic kidney disease (dysfunction of kidneys that never gets better). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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

Inspectors wroteBased 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. [...]