Inspection Reports for
Wells Nursing Home Inc
201 W Madison Avenue, Johnstown, NY, 12095
Back to Facility Profile4 Reports
Inspection Report — Sep 12, 2024
Annual Inspection CMS
Date: Sep 12, 2024
Visit Reason
The inspection was a recertification and abbreviated survey to assess compliance with regulatory requirements for Wells Nursing Home Inc.
Findings
The facility was found noncompliant in three key areas: failure to provide timely 2-day notification of Medicare service termination to residents, neglect resulting in a resident fall causing a pelvis fracture, and improper labeling and storage of medications on one medication cart.
Citations (3)
F 0582: The facility did not ensure residents #141 and #142 received timely 2-day notification of Medicare service termination with the required Notice of Medicare Non-Coverage form.
F 0600: Certified Nurse Aide #2 failed to use two-person assist as required for Resident #48, resulting in the resident falling from bed and sustaining a pelvis fracture, causing actual harm.
F 0761: The facility did not ensure drugs and biologicals were labeled and stored properly; opened insulin pens on the 2nd floor medication cart lacked open and expiration dates.
Report Facts
Residents reviewed for abuse and neglect: 18
Residents affected by neglect deficiency: 1
Residents affected by notification deficiency: 2
Medication carts reviewed: 2
Suspension duration: 4
Quality Assurance audit residents per month: 10
Quality Assurance audit duration: 3
Quality Assurance audit staff members: 4
Quality Assurance audit monthly staff members: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Certified Nurse Aide | Named in neglect deficiency for failing to use two-person assist and suspended for 4 weeks |
| Registered Nurse #1 | Registered Nurse | Documented resident assessment after fall and provided statements on staff education |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed medication cart and provided statements on medication labeling |
| Director of Nursing #1 | Director of Nursing | Provided statements on staff education, quality assurance, and medication labeling policies |
Inspection Report — Sep 12, 2024
Complaint Investigation State
Date: Sep 12, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2026 with citation and complaint history, enforcement actions, and detailed inspection findings.
Complaint Details
The facility received 27 complaints with 4 resulting in on-site inspections. Three citations resulted from complaints during the reporting period.
Findings
Across 4 inspections, 3 had no citations while 1 inspection resulted in 5 citations including 3 standard health and 2 life safety code violations. The facility had 27 complaints with 4 on-site inspections and 2 enforcement actions totaling $12,000 in fines.
Citations (5)
Free From Abuse And Neglect: Standard Health Citation for quality of care related to abuse and neglect.
Label/store Drugs And Biologicals: Standard Health Citation for quality of care regarding medication labeling and storage.
Medicaid/medicare Coverage/liability Notice: Standard Health Citation for quality of care related to coverage and liability notices.
Plan Based On All Hazards Risk Assessment: Life Safety Code Citation for NFPA requirements on hazard risk planning.
Roles Under A Waiver Declared By Secretary: Life Safety Code Citation for NFPA requirements on roles under waiver.
Report Facts
Inspections on page: 4
Total citations: 5
Inspections with violations: 1
Inspections without violations: 3
Total complaints: 27
On-site complaint inspections: 4
Total enforcement actions: 2
Total fines: 12000
Citations issued from complaints: 3
Inspection Report — Oct 27, 2021
Renewal CMS
Date: Oct 27, 2021
Visit Reason
The inspection was conducted as a recertification survey to evaluate compliance with food service safety standards during the facility's renewal process.
Findings
The facility failed to store, prepare, distribute, and serve food according to professional standards. Specifically, the concentration of quaternary ammonium compound sanitizer was below manufacturer requirements and refrigerator shelving and door gaskets were soiled.
Citations (1)
F0812: The concentration of quaternary ammonium compound sanitizer was 150 ppm, below the required 200-400 ppm range. Refrigerator shelving and door gaskets in the nourishment area were soiled with food particles.
Report Facts
Sanitizer concentration (ppm): 150
Required sanitizer concentration range (ppm): 200
Required sanitizer concentration range (ppm): 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding staff education on sanitizer concentration and refrigerator cleaning | |
| Administrator | Interviewed regarding oversight of sanitizer concentration and cleaning compliance |
Inspection Report — May 9, 2019
Annual Inspection CMS
Date: May 9, 2019
Visit Reason
The survey was a recertification and abbreviated survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, physician notification for significant changes, care planning, pain management, oxygen use, food safety, staff education on dementia care, and life safety code compliance related to carbon monoxide detection.
Citations (11)
F 0550: The facility did not ensure residents were treated with dignity and respect, including proper staff interaction during meals, privacy protection, honoring feeding refusals, and maintaining personal space.
F 0580: The facility failed to notify the physician of significant changes in Resident #42's condition related to frequent loose stools and rectal irritation.
F 0582: The facility did not provide required notification to residents or representatives regarding Medicare Part A coverage and potential liability for services not covered.
F 0656: The facility did not develop and implement comprehensive, person-centered care plans addressing residents' specific needs, including pain management and continence.
F 0660: The facility failed to plan and document discharge goals and referrals for Resident #22 who expressed a desire to return to the community.
F 0695: The facility did not ensure safe and appropriate respiratory care, lacking physician orders for oxygen flow rates and indications for use for Residents #59 and #70.
F 0697: The facility failed to provide adequate pain management consistent with professional standards and residents' needs for Residents #42, #70, and #91.
F 0812: The facility did not maintain proper food service safety; sanitizer concentration was below required levels, and food contact and non-food contact surfaces were unclean.
F 0813: The facility lacked a policy for safe use and storage of foods brought in by family and visitors, including education on safe food handling and assistance for residents unable to self-feed.
F 0836: The facility did not provide carbon monoxide detection in areas with gas fuel-fired equipment as required by fire code.
F 0943: The facility did not provide staff education on dementia care including conflict resolution, anger management, and addressing staff burnout and stress.
Report Facts
Pain level: 10
Pain level: 7
Pain level: 10
Oxygen flow rate: 1.5
Oxygen flow rate: 1
Sanitizer concentration: 0
Medication administration count: 152
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #7 | Registered Nurse | Provided dementia care in-service lacking conflict resolution and burnout education |
| Director of Nursing | Interviewed regarding multiple deficiencies including pain management and oxygen orders | |
| Medical Director | Interviewed regarding oxygen orders and pain management | |
| Dietary Director | Interviewed regarding food service sanitizing and food brought in by visitors | |
| Plant Operations Director | Interviewed regarding lack of carbon monoxide detection |
Viewing
Loading inspection reports...
