Wellsville Manor Care Center

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased on interviews conducted during the Standard survey completed on 6/14/24, the facility did not assure the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service. Specifically, the facility did not ensure there was postal service available on Saturdays. This involved Resident #s 22, 30, 36, 44, 49, 82, 84, and 258. The finding is: On 6/11/24 at 10:13 AM, the Resident Council attendees (Resident #s 30, 36, 44, 49, 82, 84, and 258) stated they did not receive mail on Saturdays because they believed the facility didn't have staff available to deliver mail on Saturdays. During an interview on 6/12/24 at 10:51 AM, the Activities Department Director stated the United States Postal Service delivered mail to the facility Monday through Friday. [...]

Inspectors wroteBased on interviews and record review conducted during a Complaint investigation (Complaint #NY00312806) during the Standard survey completed on 6/14/24, the facility did not the facility did not make prompt efforts to resolve grievances for one (Resident #257) of three residents reviewed for grievances. Specifically, there was lack of follow through and resolution of a resident's report of missing property. The finding is: Review of a facility policy and procedure titled Resident Grievance, revised 1/2024 revealed that the Social Work Department will inform residents and/or designated representatives of their right to express grievances with the expectation of a response and without fear of reprisal. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview, observation and record review conducted during the Standard survey started on 7/18/22 and completed on 7/22/22, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for three (Residents #49, 67, and 88) of three residents reviewed. Specifically, preferred number of showers per week were not obtained (#49), preferred wake up time was not obtained (#67), and showers were not provided in accordance with resident wishes' (#88).

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]