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Deficiency Records for Wellsville Health Care Center
A list of the most recent deficiencies for Wellsville Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Wellsville Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-04-04 | 2024-05-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-04 | 2024-05-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-04-04 | 2024-05-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-04 | 2024-05-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-04 | 2024-05-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-04-04 | 2024-05-20 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-04 | 2024-05-20 | N |
| Help the resident with transportation to and from laboratory services outside of the facility. | Health | 2024-04-04 | 2024-05-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-04-04 | 2024-05-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-04-04 | 2024-05-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-04-04 | 2024-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-04 | 2024-05-20 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-04-04 | 2024-05-20 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-04-04 | 2024-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-04 | 2024-05-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-04 | 2024-05-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-04 | 2024-05-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-04-04 | 2024-05-20 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-04 | 2024-05-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-29 | 2023-05-13 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-29 | 2023-05-13 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-29 | 2023-05-10 | N |
| Meet other general requirements. | Fire Safety | 2023-03-29 | 2023-05-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-29 | 2023-05-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-29 | 2023-05-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-29 | 2023-05-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-29 | 2023-05-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-29 | 2023-05-10 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-03-29 | 2023-05-02 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-29 | 2023-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-29 | 2023-04-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-29 | 2023-04-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-29 | 2023-04-25 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-29 | 2023-04-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-29 | 2023-04-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-29 | 2023-04-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-03-29 | 2023-04-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-29 | 2023-04-20 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-03-29 | 2023-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-04-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-29 | 2023-04-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-22 | 2022-09-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-22 | 2022-09-13 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-19 | 2022-08-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-06 | 2022-06-27 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-01 | 2022-05-16 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-12-10 | 2021-01-21 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2020-12-10 | 2021-01-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-12-10 | 2021-01-21 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2020-12-10 | 2021-01-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-12-10 | 2021-01-21 | N |
| Provide activities to meet all resident's needs. | Health | 2020-12-10 | 2021-01-21 | N |
| Post nurse staffing information every day. | Health | 2020-12-10 | 2021-01-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-12-10 | 2021-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-12-10 | 2021-01-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-12-10 | 2021-01-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-12-10 | 2021-01-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-12-10 | 2021-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-12-10 | 2021-01-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-12-10 | 2021-01-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-12-10 | 2021-01-21 | N |
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