Inspection Reports for
Wells Nursing Home Inc
201 W Madison Avenue, Johnstown, NY, 12095
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
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.
Deficiencies (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
Annual Inspection
Deficiencies: 3
Date: Sep 12, 2024
Visit Reason
The inspection was a recertification and abbreviated survey to assess compliance with Medicare and Medicaid regulations for Wells Nursing Home Inc.
Findings
The survey identified deficiencies including failure to provide timely Medicare non-coverage notices to residents, neglect resulting in a resident fall causing a pelvis fracture, and improper labeling and storage of medications on one medication cart.
Deficiencies (3)
F 0582: The facility did not ensure residents #141 and #142 received timely 2-day notification of Medicare service termination using the required Notice of Medicare Non-Coverage form.
F 0600: Certified Nurse Aide #2 failed to follow the care plan requiring two-person assist for Resident #48, resulting in a fall and 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
Suspension duration: 4
Quality and Assessment audit sample size: 10
Quality Assurance audit staff count: 4
Quality Assurance audit staff count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Certified Nurse Aide | Named in neglect finding and subsequent suspension and counseling |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding fall incident and care practices |
| Registered Nurse #1 | Registered Nurse | Documented resident assessment after fall and interviewed about education |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about medication labeling and storage practices |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about education after resident fall |
| Director of Nursing #1 | Director of Nursing | Interviewed about staff education, quality assurance, and fall prevention |
| Nurse Practitioner #1 | Nurse Practitioner | Ordered hospital evaluation after resident fall |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Sep 12, 2024
Visit Reason
Complaint Survey with 3 health citations including abuse and neglect, drug labeling, and Medicaid/Medicare notice; 2 life safety code citations related to hazard risk assessment and waiver roles; all corrected.
Findings
Complaint Survey with 3 health citations including abuse and neglect, drug labeling, and Medicaid/Medicare notice; 2 life safety code citations related to hazard risk assessment and waiver roles; all corrected.
Deficiencies (5)
Free from abuse and neglect
Label/store drugs and biologicals
Medicaid/medicare coverage/liability notice
Plan based on all hazards risk assessment
Roles under a waiver declared by secretary
Inspection Report
Capacity: 60
Deficiencies: 3
Date: Dec 13, 2023
Visit Reason
Covid-19 Survey with 3 life safety code citations related to electrical systems, gas equipment training, and sprinkler system maintenance; all corrected.
Findings
Covid-19 Survey with 3 life safety code citations related to electrical systems, gas equipment training, and sprinkler system maintenance; all corrected.
Deficiencies (3)
Electrical systems - essential electric syste
Gas equipment - qualifications and training
Sprinkler system - maintenance and testing
Inspection Report
Renewal
Deficiencies: 1
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.
Deficiencies (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
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Oct 27, 2021
Visit Reason
Complaint Survey with 2 health citations including food procurement sanitation and construction standards; 2 life safety code citations including electrical equipment testing and emergency preparedness training; all corrected.
Findings
Complaint Survey with 2 health citations including food procurement sanitation and construction standards; 2 life safety code citations including electrical equipment testing and emergency preparedness training; all corrected.
Deficiencies (4)
Food procurement,store/prepare/serve-sanitary
Standards of construction for new existing nh
Electrical equipment - testing and maintenanc
Ep training program
Inspection Report
Annual Inspection
Deficiencies: 11
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.
Deficiencies (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 |
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