Inspection Reports for
Manor Hills
4192-B Bolivar Road, Wellsville, NY 14895, NY, 14895
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation (#NY00312806) regarding the facility's failure to promptly resolve a resident grievance about missing personal property.
Complaint Details
Complaint investigation #NY00312806 found the facility did not follow through on a grievance for missing eyeglasses for Resident #257. The grievance was substantiated with evidence of lack of follow-up and resolution.
Findings
The facility failed to make prompt efforts to resolve grievances for one resident related to missing eyeglasses. Follow-up actions to have the resident seen by an eye doctor and replace the glasses were not completed as documented.
Deficiencies (1)
F 0585: The facility did not promptly resolve a resident grievance regarding missing eyeglasses and failed to ensure follow-up for replacement and eye doctor consultation.
Report Facts
Complaint number: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Work Department Director | Named in relation to failure to follow up on resident grievance and missing glasses | |
| Director of Medical Records Department | Named in relation to failure to follow up on resident grievance and missing glasses | |
| Unit Manager Licensed Practical Nurse #2 | Unit Manager Licensed Practical Nurse | Commented on expected follow-up for missing glasses grievance |
| Administrator | Administrator | Responsible for ensuring follow-up on resident grievance and replacement of glasses |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 14, 2024
Visit Reason
The survey was a standard routine inspection conducted to assess compliance with regulatory requirements including resident rights, grievance resolution, care planning, staffing qualifications, and infection control.
Complaint Details
Complaint investigation #NY00312806 found the facility did not make prompt efforts to resolve grievances for Resident #257 related to missing property (eyeglasses). The grievance was substantiated with documented lack of follow-up and no replacement of the glasses.
Findings
The facility was found deficient in ensuring residents' rights to mail delivery on Saturdays, timely resolution of grievances, appropriate use of assistive devices, sufficient qualified food and nutrition staff, and proper infection prevention and control practices including hand hygiene and enhanced barrier precautions during wound care.
Deficiencies (5)
F 0576: The facility did not ensure residents had the right to send and receive mail on Saturdays, lacking postal service availability and mail delivery process on that day.
F 0585: The facility failed to make prompt efforts to resolve grievances for Resident #257 regarding missing eyeglasses, with lack of follow-through and no replacement provided.
F 0688: Resident #58 with limited range of motion did not consistently wear the prescribed right hand splint as ordered, risking contracture and further decline.
F 0801: The facility did not employ sufficient staff with appropriate competencies and skills for food and nutrition services, lacking a full-time qualified dietitian or clinically qualified nutrition professional.
F 0880: The facility failed to provide and implement an infection prevention and control program, including inadequate hand hygiene and lack of enhanced barrier precautions during wound care for Resident #307 with pressure ulcers.
Report Facts
Days worked per week: 2
Date of survey completion: Jun 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in infection control deficiency for missed hand hygiene during wound care. |
| Registered Nurse #3 | Registered Nurse | Named in infection control deficiency and wound care observation. |
| Dietary Supervisor #2 | Food Service Director | Named in staffing deficiency for lack of certification and full-time qualified status. |
| Dietitian #1 | Registered Dietitian | Named in staffing deficiency for working less than full-time. |
| Social Work Department Director | Named in grievance deficiency for lack of follow-up on missing glasses grievance. | |
| Administrator | Named in multiple deficiencies including mail delivery, grievance follow-up, care plan compliance, staffing qualifications, and infection control oversight. | |
| Director of Nursing | Named in care plan compliance and infection control deficiencies. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The visit was conducted as an abbreviated survey triggered by Complaint #NY00338118 regarding alleged abuse at the facility.
Complaint Details
The complaint investigation found that Certified Nurse Aide #1 witnessed another aide muffling Resident #1's screams with a pillow and stuffed animal on 4/2/24 but did not report it immediately. The incident was reported to the New York State Department of Health on 4/4/24 by the Administrator after the scheduler received an email from Certified Nurse Aide #1. Staff interviews confirmed failure to report abuse timely.
Findings
The facility failed to ensure timely reporting of suspected abuse involving Resident #1. Staff did not report the alleged abuse immediately to the Director of Nursing or Administrator, resulting in delayed notification to the New York State Department of Health.
Deficiencies (1)
F 0609: The facility did not report suspected abuse of Resident #1 immediately, delaying notification to the appropriate authorities. Certified Nurse Aide #1 witnessed abuse but did not report it until the following day.
Report Facts
Complaint number: Complaint #NY00338118 triggered the abbreviated survey.
Date of incident: Incident occurred on 2024-04-02.
Date of report to State Department of Health: Reported on 2024-04-04.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Witnessed abuse and delayed reporting. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Alleged perpetrator of abuse involving Resident #1. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed; stated they were unaware of abuse allegations. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Interviewed; stated no abuse concerns were reported on 4/2/24. |
| Director of Nursing | Director of Nursing | Stated abuse should have been reported immediately. |
| Administrator | Administrator | Reported incident to State Department of Health and emphasized importance of immediate reporting. |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 22, 2022
Visit Reason
The inspection was conducted as a standard survey to assess compliance with regulatory requirements related to resident rights, provider face-to-face visits, and care practices.
Findings
The facility failed to promote and facilitate resident self-determination regarding personal care preferences for three residents, did not ensure required face-to-face provider visits for three residents, and had documentation issues related to bathing schedules and provider visits.
Deficiencies (2)
F 0561: The facility did not ensure resident self-determination through support of resident choice for three residents regarding shower frequency, wake-up time, and shower provision.
F 0712: The facility did not ensure that residents and their doctors met face-to-face at all required visits for three of nine residents reviewed, with visits conducted via telehealth instead of in person.
Report Facts
Residents affected: 3
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Unit Manager | Named in interviews regarding bathing schedules and provider visits |
| Director of Nursing | DON | Named in interviews regarding documentation and provider visits |
| Director of Recreation Services | Named in interview regarding resident preferences | |
| RN #3 | Unit Manager | Named in interview regarding provider visits |
| LPN Assistant Director of Nursing #1 | Assistant Director of Nursing | Named in interview regarding scheduling provider visits |
| NP | Nurse Practitioner | Named in interviews regarding telehealth visits |
| MD | Medical Doctor | Named in interviews regarding face-to-face visit requirements |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 2, 2019
Visit Reason
The facility underwent a standard routine survey inspection to assess compliance with regulatory requirements related to employee screening, dialysis care, psychotropic medication use, and other care standards.
Findings
The inspection identified deficiencies including failure to implement proper employee screening through the NYS Nurse Aide Registry, inadequate collaboration and documentation regarding dialysis dressing care for a resident, and insufficient documentation and oversight of antipsychotic medication use for another resident.
Deficiencies (3)
F 0607: The facility did not implement written policies and procedures for screening employees through the NYS Nurse Aide Registry, failing to verify four of eight employees prior to employment.
F 0698: The facility did not ensure residents requiring dialysis received appropriate care, lacking collaboration with the dialysis center regarding removal of dialysis dressings post-treatment.
F 0758: The facility did not ensure psychotropic medications were only given when necessary, lacked behavior documentation supporting antipsychotic use, and delayed acting on gradual dose reduction recommendations for one resident.
Report Facts
Employees not screened: 4
Residents reviewed for dialysis: 1
Residents reviewed for psychotropic medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Human Resources Coordinator | Named in finding for lack of Nurse Aide Registry screening. |
| Employee #5 | Licensed Practical Nurse | Named in finding for lack of Nurse Aide Registry screening. |
| Employee #6 | Registered Nurse | Named in finding for lack of Nurse Aide Registry screening. |
| Employee #7 | Certified Nurse Aide | Named in finding for lack of Nurse Aide Registry screening. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding antipsychotic medication use. |
| Licensed Practical Nurse #1 | Charge Nurse | Interviewed regarding dialysis dressing care. |
| Director of Nursing | Director of Nursing | Interviewed regarding dialysis dressing care and antipsychotic medication documentation. |
| Physician | Physician | Interviewed regarding antipsychotic medication orders and recommendations. |
| Social Work | Social Worker | Interviewed regarding behavioral documentation for antipsychotic medication. |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding dialysis dressing care instructions. |
Inspection Report
Deficiencies: 0
Date: Inspection Report
Visit Reason
Inspection Reports covering citations and enforcement actions from August 1, 2021 through July 31, 2025
Findings
The Operator of this facility received no citations or enforcement actions from any inspection during the reporting period.
Report Facts
Total inspections: No inspections with citations or enforcement actions reported from 2021-08 to 2025-07
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