Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellsville Manor during CMS and state inspections, most recent first.
Lack of Full-Time Dietary Leadership: The facility did not have a full-time CDM or qualified dietician/clinically qualified nutrition professional on site to oversee kitchen staff and residents’ dietary needs. Dietary Staff BB was serving as CDM for two kitchens while also working at another facility, and Consultant GG stated she oversaw seven facility kitchens and only visited this facility on Fridays; neither she nor the CDM worked over 35 hours per week at the facility.
A facility failed to ensure effective dish sanitizing in a secondary kitchen when the sanitizer cycle reached only 111 degrees F instead of the required 120 degrees F. Dietary staff observed the low temperature while running glassware through the sanitizer, and maintenance staff confirmed the required setting.
Failure to Perform Hand Hygiene and Clean Shared Equipment: Two CNAs cared for a resident on EBP and changed a soiled brief without changing gloves or performing hand hygiene. The same Hoyer lift was then moved to another resident's room and used again without being cleaned, and later placed in clean storage still unsanitized. Staff interviews showed conflicting understanding of who was responsible for cleaning the lift after resident use.
Failure to Obtain Psychotropic Medication Consent: A resident with major depressive disorder and intact cognition was prescribed sertraline, but the EMR showed no indication that the resident or representative was informed of the medication’s risks, benefits, or side effects. The psychotropic medication consent was uncompleted and unsigned, and an RN stated the consent had been skipped over.
Failure to Monitor Hypnotic Medication: A resident with insomnia and major depressive disorder received nightly zolpidem (Ambien), but the MDS and psychotropic CAA did not accurately document the hypnotic use or insomnia diagnosis. The care plan referenced Ambien and monitoring needs, yet the EMR lacked evidence of ongoing monitoring for side effects and effectiveness, and staff stated there was no reminder to monitor the medication or document its effectiveness.
A facility failed to provide written transfer/discharge notices with appeal rights to two residents who were sent to the hospital and failed to notify the ombudsman of the transfers. One resident with sepsis, UTI, and nephrostomy tubes had repeated hospital transfers for fever, pain, and worsening symptoms, and the EMR lacked bed-hold documentation after discharge to the hospital. A second resident was transferred by ambulance for chest pain radiating to the jaw and arms, but the record still lacked the required written notice and ombudsman notification.
A facility failed to accurately complete MDS assessments for two residents. One resident with major depressive disorder was receiving sertraline, but the antidepressant was not documented on the MDS, so the psychotropic CAA was not triggered and the admission CAA/care plan did not reflect it. Another resident with insomnia and major depressive disorder was receiving zolpidem, but the hypnotic was not documented on the MDS; the psychotropic CAA did not include the hypnotic or insomnia, and the care plan was not updated with psychotropic use documentation.
Failure to Implement and Monitor Fall Interventions: A resident with dementia, moderate cognitive impairment, wheelchair dependence, and a history of falls had a care plan with fall precautions, but staff did not consistently follow or clearly understand the interventions. The resident was found after an unwitnessed fall while trying to transfer to the commode without using the call light, and observations showed the bed was at times raised well above the floor instead of being in the lowest position.
Nephrostomy Drainage Bags Positioned Above Bladder Level: A resident with bilateral nephrostomy tubes, UTI, sepsis, and kidney infection was observed sitting in a recliner with the urine collection bags placed in chest pockets on an apron while staff watched TV with the resident. The resident’s care instructions and facility policy stated the drainage bags were to remain below the bladder or kidney insertion site, and an LPN later moved the bags after confirming they were not to be above bladder level.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as dried-on food and liquid substances on trash cans, food debris on preparation shelves, and buildup in freezers and on utensils. Dietary staff confirmed these concerns, and the facility lacked a policy for kitchen cleanliness.
The facility inaccurately assessed the use of bedrails as restraints for four residents, despite observations and interviews confirming their use for mobility and independence. The MDS coding errors affected 31 residents' assessments, contradicting the facility's restraint-free policy.
The facility failed to complete a Significant Change MDS within the required 14-day period for two residents admitted to hospice care. One resident with dementia and another with a history of CVA were both admitted to hospice, but the facility did not complete the necessary assessments. The care plans were revised without proper instructions for hospice care, and the facility was unaware of the requirement for significant change MDS upon hospice admission.
A resident with severe cognitive impairment was admitted to hospice care for cerebrovascular disease, but the facility failed to update the care plan with hospice care instructions. Despite a physician's order and facility policy requiring timely updates to care plans, the revised care plan lacked necessary guidance for staff, leading to a deficiency finding.
A resident with COPD did not receive timely nebulizer treatment due to the facility's lack of appropriate-sized masks, resulting in a delay of medication administration. The facility had only pediatric masks available, which were unsuitable for the resident, leading to a missed dose and a significant delay in treatment.
Lack of Full-Time Dietary Leadership
Penalty
Summary
The facility failed to provide the services of a full-time Certified Dietary Manager (CDM) for residents who received meals from the kitchen. On 05/20/26 at 11:00 AM, Dietary Staff BB verified that she was the CDM for the two facility kitchens but also continued to work at another facility. During an interview on 05/21/26 at 09:35 AM, Administrative Staff A stated there should be a full-time CDM on site and that this was the expected transition for Dietary Staff BB. Administrative Staff A also verified there should be a qualified dietician or other clinically qualified nutrition professional working full-time in the facility to oversee the kitchen staff and residents’ dietary needs. During an interview on 05/21/26 at 11:05 AM, Consultant GG verified she was overseeing seven facility kitchens and currently visited this facility on Fridays, and then verified that neither she nor the CDM were working over 35 hours a week at the current facility.
Sanitizer Temperature Below Required Level
Penalty
Summary
The facility failed to ensure effective sanitizing of dishes in one of its two kitchens when the sanitizer did not reach the required 120 degrees Fahrenheit. During an observation on 05/20/26 at 12:15 PM, Dietary Staff EE ran a cycle of glassware through the sanitizer in the secondary kitchen and verified that the temperature was 111 degrees Fahrenheit. During an interview on 05/20/26 at 12:30 PM, Maintenance Staff U confirmed that the sanitizer temperature should be 120 degrees Fahrenheit. Later that day at 03:00 PM, Maintenance Staff U stated that the sanitizer temperature was adjusted to 120 degrees Fahrenheit. The facility's undated Dietary Services Leadership & Shared CDM Policy stated that residents are to receive safe, sanitary, and nutritionally adequate meals in accordance with physician orders, resident preferences, and regulatory requirements.
Failure to Perform Hand Hygiene and Clean Shared Equipment
Penalty
Summary
The facility failed to implement adequate infection control practices when two CNAs cared for a resident on Enhanced Barrier Precautions and changed a soiled brief without changing gloves or performing hand hygiene. On 05/20/2026 at 01:25 PM, CNA P and CNA N used a Hoyer lift to transfer Resident 35 from a wheelchair to the bed for brief care. Although they washed their hands and applied PPE before the transfer, they removed the soiled brief and applied a clean brief without changing gloves and without performing hand hygiene before continuing care. The same Hoyer lift was then moved from Resident 35's room to Resident 29's room across the hall without being cleaned. At 01:35 PM, CNA P and CNA N used the unsanitized lift to transfer Resident 29 from a wheelchair to the bed. At 01:50 PM, CNA N placed the Hoyer lift into the clean storage area with the other lift without cleaning it. During interviews, CNA P stated day shift did not clean the Hoyer lifts after resident use and that night shift was responsible for cleaning the equipment later that night. LN G stated staff were supposed to clean the Hoyer lift after each resident use and that night shift was responsible for deep cleaning. Administrative Nurse E stated the Hoyer lift was to be cleaned after each resident use and deep cleaned by night shift, and said day shift staff had been educated on cleaning the Hoyer lift after each resident use.
Failure to Obtain Psychotropic Medication Consent
Penalty
Summary
The facility failed to inform Resident 5 or her representative about the risks and benefits of taking sertraline, an antidepressant used to treat major depressive disorder. Resident 5’s EMR documented major depressive disorder, and her admission MDS showed a BIMS score of 14, indicating intact cognition. Her care plan included use of an antidepressant to improve functioning and reduce symptoms, and physician orders showed sertraline 50 mg every evening. The EMR also contained a Consent for Use of Psychotropic Medication dated 03/16/26, but the assessment was uncompleted and the consent was unsigned. The record review showed no indication that Resident 5 or her representative was notified about the medication, including its risks, benefits, or potential side effects. On 05/21/26, Administrative Nurse F stated Administrative Nurse D completed medication consents, and Administrative Nurse D stated that in March they realized psychotropic medication consents had not been done and began completing them at that time. Administrative Nurse D verified that the resident or representative did not consent to the medication and stated it must have been skipped over.
Failure to Monitor Hypnotic Medication
Penalty
Summary
The facility failed to accurately assess and monitor a psychotropic medication for a resident who had diagnoses of insomnia and major depressive disorder and a BIMS score of 14, indicating intact cognition. The resident’s EMR showed nightly Ambien (zolpidem) ordered for insomnia, but the admission MDS did not accurately document the hypnotic medication, and the psychotropic drug use CAA did not document the hypnotic or the diagnosis of insomnia. The resident’s care plan identified Ambien and noted a Black Box Warning, with directions to monitor pain, sleep patterns, and respirations, but the EMR lacked evidence of monitoring for side effects and effectiveness of the ongoing use of Ambien. During observation, the resident was reclined in a recliner with her feet up and stated that all she did all day was lay there and that she liked staying in her room. Staff interviews indicated that the facility did not have a reminder to monitor zolpidem and had not been monitoring this hypnotic medication for sleep. An administrative nurse stated that Ambien should have been added to the care plan at admission so staff could document the medication’s effectiveness, and another administrative nurse stated the medication was then added to the care plan so the nurse would document it. The facility policy stated that medications should be used only when clinically indicated and monitored for effectiveness and adverse consequences with appropriate documentation.
Failure to Provide Transfer Notices, Ombudsman Notification, and Bed-Hold Information
Penalty
Summary
The facility failed to provide written transfer notifications to the resident and/or representative as soon as practicable for two residents who were sent to the hospital, and it failed to send a copy of those notifications to the ombudsman. For one resident with sepsis, UTI, and nephrostomy tubes, the record showed multiple hospital transfers after fever, pain, red urine, and worsening symptoms, including episodes when the physician ordered emergency evaluation and the resident was sent out. The resident’s EMR did not contain documentation of the required written transfer notice, ombudsman notification, or bed-hold information provided to the resident or representative upon discharge to the hospital. For the second resident, the nurse documented chest pain radiating to the jaw and arms, the physician ordered emergency room evaluation, and the resident was transported by ambulance. The EMR for this resident also lacked documentation of a written notification explaining the reason for transfer and appeal rights, and there was no documentation that the ombudsman was notified. Staff interviews indicated the ombudsman was not notified of transfers or discharges, and one staff member stated she was unaware of the requirement to provide bed-hold information and written transfer/discharge notification.
MDS assessments did not accurately capture psychotropic medications for two residents
Penalty
Summary
The facility failed to accurately complete the MDS for Resident 5 and Resident 27 during admission assessment. Resident 5 had diagnoses including major depressive disorder, and the 06/10/25 MDS documented a BIMS score of 14 and listed a diuretic, opioid, hypoglycemic, and anticonvulsant, but did not accurately document the antidepressant sertraline 50 mg that was ordered on 05/29/25 and administered daily from 06/04/25 through 06/10/25. Because the antidepressant was not accurately entered on the MDS, the Psychotropic Drug Use CAA was not triggered, and the CAA and care plan did not reflect the antidepressant at admission. Resident 5 was observed on 05/21/26 sitting in a recliner watching television and appeared relaxed and comfortable. Resident 27 had diagnoses including insomnia and major depressive disorder, and the 09/08/25 MDS documented a BIMS score of 14 and listed an antidepressant, anticoagulant, and opioid, but did not accurately document the hypnotic zolpidem 10 mg ordered on 09/02/25 and administered daily from 09/02/25 through 09/08/25. The Psychotropic Drug Use CAA documented pain medication management but did not include the hypnotic or the diagnosis of insomnia, and the care plan was not updated with the psychotropic use care plan for nurse documentation of behaviors and side effects. On 05/19/26, Resident 27 was observed reclined in a chair with her feet up, requested that her bed be switched out for the recliner, and stated that she stayed in her room and lay there all day.
Failure to Implement and Monitor Fall Interventions
Penalty
Summary
The facility failed to identify, implement, and monitor resident-centered fall interventions for a resident who was at high risk for falls. The resident had multiple diagnoses including pneumonitis, sepsis, polyosteoarthritis, encephalopathy, dementia, atrial fibrillation, HTN, UTI, overactive bladder, and diarrhea. Her MDS documented a BIMS score of 8, indicating moderate cognitive impairment, and she required a wheelchair for mobility, setup assistance for eating, and substantial to maximal assistance for most ADLs. Her care plan identified fall risk related to weakness, impaired balance, incontinence, and disease conditions, and listed interventions such as placing the bed in the lowest position, keeping a bedside commode in the bathroom with the curtain pulled, and providing frequent visual checks during a specified time period. The resident had a history of falls, including an unwitnessed fall with injury in which she was found on the floor in front of her wheelchair near the bathroom grab bar after attempting to transfer to the commode without using her call light. The progress note documented that neurological assessments were initiated because she had a BIMS score of 5 at that time. During observation, the resident was seen with her bed raised approximately three to four feet from the floor and not in the lowest position, and later with the bed in a low position and a fall mat at the bedside. Staff interviews showed inconsistent understanding of the care plan: an Administrative Nurse could not define or quantify frequent checks, and CNAs described different fall interventions, including leaving the bathroom door propped open with a trash can and using the bed in the lowest position with a fall mat, while also stating the bedside commode was kept in the bathroom blocking the doorway.
Nephrostomy Drainage Bags Positioned Above Bladder Level
Penalty
Summary
The facility failed to ensure that a resident with bilateral nephrostomy tubes received appropriate treatment and services to prevent urinary tract infections to the extent possible. The resident’s EMR documented diagnoses of sepsis, UTI, and kidney infection, and the admission MDS noted an indwelling catheter and antibiotic use. The urinary incontinence and indwelling catheter CAA stated the resident was in isolation for a UTI and had nephrostomy tubes in both kidneys that staff were managing. The resident’s nephrostomy tube care instructions stated the drainage bag should always remain below the bladder and never be higher than the bladder. During observation, the resident was sitting in a recliner with an apron that had pockets on the chest, and the urine collection bags were positioned in those chest pockets while the resident watched television. A CNA stated the resident was dependent on staff for all transfers and that the bags were kept on the side of the bed when the resident was in bed. An LPN later stated the bags were supposed to be in the bags on the sides of the recliner and were never to be above the level of the resident’s bladder, and then moved the bags. The administrative nurse stated it was her expectation that staff always keep the urine collection bags below the level of the bladder to prevent back flow and infection. The facility policy also stated drainage bags are to remain below the level of the bladder or kidney insertion site.
Unsanitary Kitchen Conditions Identified
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially lead to foodborne bacteria affecting the residents. During an initial tour of the kitchen, several areas of concern were identified. These included trash cans in the dishwashing and handwashing areas that had dried-on food and liquid substances on all sides and lids. Additionally, the shelf under a preparation table, which held plastic pitchers, cutting boards, and clean eating utensils, contained food debris. The inside of the microwave was found to have dried-on food on all sides and the top, and four colored cutting boards were noted to have deep grooves and discoloration. Further observations revealed an oscillating fan with a buildup of dust, dried-on food substances on one side of the stove, and a buildup of food substances and a black substance in the rubber door seals of one of the reach-in freezers. Three plastic tubs beneath a prep table, which held clean cooking utensils, contained a sticky substance, and five plastic containers on a wire rack had a heavy buildup of food debris and a sticky substance on the container latches. The table holding the large stand mixer also had a buildup of food substance on the bottom shelf. Dietary staff confirmed these concerns and acknowledged the need for a cleaning schedule. The facility lacked a policy for kitchen cleanliness, contributing to the unsanitary conditions observed.
Inaccurate MDS Assessments for Bedrail Use
Penalty
Summary
The facility failed to complete accurate assessments for four residents regarding the use of bedrails as restraints. Resident 23, who was cognitively intact with a BIMS score of 15, used bedrails for repositioning and independence, not as restraints. Observations and interviews confirmed that the bedrails did not restrict her movement, yet the MDS inaccurately coded them as restraints. This error was acknowledged by the facility's administrative nurse, who confirmed that the MDS Coordinator had inaccurately coded the use of bedrails, affecting 31 residents' assessments. Resident 37, with severe cognitive impairment, also used bedrails for mobility and independence. Despite the resident's ability to move without limitation and the bedrails aiding her balance, the MDS inaccurately recorded the bedrails as restraints. Interviews with staff confirmed that the facility did not use bedrails as restraints, and the administrative nurse verified the coding error, which was consistent with the facility's policy of maintaining a restraint-free environment. Similarly, Residents 2 and 13 were inaccurately assessed regarding their use of bedrails. Resident 2, with normal cognitive status, used bedrails for mobility and independence, while Resident 13, with moderately impaired cognitive status, used bedrails for positioning assistance. In both cases, the MDS inaccurately coded the bedrails as restraints, contrary to the facility's policy and the residents' actual use of the bedrails. The administrative nurse confirmed these inaccuracies, highlighting a systemic issue with the MDS assessments related to bedrail use.
Failure to Complete Significant Change MDS for Hospice Admissions
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) within the required 14-day period for two residents who were admitted to hospice care. Resident 19, diagnosed with dementia, was admitted to hospice care for cerebrovascular disease, but the facility did not complete the necessary significant change MDS. The resident's care plan was revised without including instructions regarding hospice care, and the facility was unaware of the requirement to complete a significant change MDS upon hospice admission. Similarly, Resident 44, who had a history of cerebrovascular accident (CVA) and moderate cognitive impairment, was admitted to hospice care. However, the facility again failed to complete the significant change MDS as required. The resident's care plan indicated hospice care for end-of-life support, but the facility did not recognize the need for a significant change MDS. In both cases, the facility utilized the Resident Assessment Instrument (RAI) for MDS completion but did not adhere to the regulatory requirement for significant change assessments.
Failure to Update Care Plan for Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident who was admitted to hospice care. The resident, identified as having severe cognitive impairment due to dementia, was documented in the Significant Change Minimum Data Set (MDS) as not having a condition or chronic disease that would result in a life expectancy of less than six months during the assessment period. However, a subsequent Quarterly MDS indicated that the resident had a condition that could result in a life expectancy of less than six months and was receiving hospice care. Despite the physician's order to admit the resident to hospice care for cerebrovascular disease, the care plan, revised on 08/13/24, did not include instructions for staff regarding hospice care. The facility's policy stated that care plans should be updated timely when changes in a resident's condition occur, including when a resident is admitted to hospice care. The lack of comprehensive instructions in the care plan for hospice care was identified as a deficiency during the survey.
Inadequate Nebulizer Equipment for Resident with COPD
Penalty
Summary
The facility failed to provide appropriate nebulizer equipment for a resident with chronic obstructive pulmonary disease (COPD), leading to a deficiency in respiratory care. The resident, who had a normal cognitive status and required oxygen therapy, was prescribed ipratropium-albuterol breathing treatments every six hours. However, on one occasion, the treatment was delayed because the facility only had pediatric-sized masks, which were unsuitable for the resident. This resulted in the resident missing a scheduled dose and receiving the next dose 15 and a half hours later. The issue was identified when a Certified Medication Aide attempted to administer the medication and found the mask did not fit properly. Despite efforts to locate an appropriate mask or inhalation device within the facility, none were available. The deficiency was confirmed through interviews with facility staff, who acknowledged the receipt of incorrect mask sizes and the subsequent need to obtain the correct supplies from a local retailer. The facility's policy on nebulizer treatment emphasized the importance of using proper equipment to ensure effective medication delivery, which was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 227 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wellsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baldwin Healthcare & Rehab Center, Llc | 7.2 mi | ★★★★★ | 11 | 0 |
| Meadowbrook Rehabilitation Hospital | 10.2 mi | ★★★★★ | 21 | 1 |
| Rock Creek Of Ottawa | 13.6 mi | ★★★★★ | 1 | 0 |
| Spring Hill Care And Rehab | 14.3 mi | ★★★★★ | 1 | 1 |
| North Point Skilled Nursing Center | 14.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wellsville Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.