Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Health Care Center during CMS and state inspections, most recent first.
Facility staff did not provide a full-time DON as required for facilities with a census over 60, with the DON frequently working as a charge nurse due to staffing shortages. Staff and administrator interviews confirmed that the DON was responsible for administrative duties but also covered nursing shifts to maintain coverage, and the facility lacked a policy for DON coverage.
The facility failed to protect a resident from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. This indicates a lapse in ensuring resident safety and well-being.
Staff did not report a revised allegation of sexual abuse between two residents to DHSS within the required two-hour window, as mandated by facility policy. Although the initial incident of inappropriate contact was reported, the subsequent, more serious allegation was not, and facility leadership could not provide a reason for this failure.
Staff failed to investigate and document an allegation of sexual abuse between two residents, as required by facility policy. A resident reported being inappropriately touched by another resident at night, but staff did not notify the physician or family, did not document the incident, and did not initiate an investigation. Leadership interviews confirmed that the required actions were not taken and the incident was not addressed according to policy.
A former administrator misappropriated $800 from a resident's digital wallet, intended for a facility bill, into their personal account. The resident, who was cognitively intact, provided evidence of the transaction, but the funds were not applied to their account, and no receipt was issued. The former administrator admitted to receiving the funds but could not provide documentation of its application. Facility records confirmed the payment was not received, and staff interviews revealed no recollection of cash being applied to the resident's bill.
The facility failed to maintain a clean and homelike environment, with observations of sticky floors, debris, and stained toilets in resident rooms. Residents expressed dissatisfaction with the cleanliness, and interviews revealed a shortage of housekeeping staff, often leaving only one housekeeper for the entire building. The facility's administrator and housekeeping staff acknowledged the challenges in maintaining cleanliness due to insufficient personnel.
The facility failed to employ a qualified Director of Food and Nutrition Services, as the Dietary Manager (DM) lacked certification and formal food service training. The DM, initially hired as a part-time cook, assumed the DM role without documented food service experience or management certification. The administrator, new to the facility, had not yet addressed the issue.
Facility staff failed to serve food according to nutritionally calculated recipes and menus, with multiple instances of unapproved meal substitutions and missing items. The Dietary Manager admitted to not consulting the dietician for meal substitutions and not maintaining the substitutions log. The administrator confirmed that the dietician had not been seen since March 2024, and food delivery issues had recently been resolved.
Facility staff failed to maintain kitchen cleanliness, properly sanitize kitchen wares, and serve food at safe temperatures. Observations revealed food debris, dust, and grease accumulation, improper sanitizer use, and food served at unsafe temperatures. The ice machine's drain line was also improperly connected, risking cross-contamination.
The facility administration failed to develop or maintain an operational policy to guide daily operations. The administrator became aware of the absence of a policy in March 2024, and the DON confirmed that the facility should not be operated without a guiding policy. The facility census was 38.
Facility staff failed to implement an Antibiotic Stewardship Program with a system to monitor antibiotic use. The new Infection Preventionist confirmed that there was no program in place and that the previous Infection Preventionist had removed all records and programs upon leaving suddenly. The DON and administrator corroborated the loss of records and the absence of the program.
Facility staff failed to maintain the privacy and confidentiality of residents' personal and medical records by leaving computer screens unattended and visible to others. Observations showed exposed resident information on computer screens in areas accessible to staff and residents. Interviews confirmed staff awareness of the requirement to close screens, but they failed to comply.
Facility staff failed to maintain a sanitary and homelike environment, with observations of a cluttered bathtub, loose baseboards, strong odors, and damaged walls and floors. Staff interviews revealed a lack of a full-time maintenance department and an absence of a clear process for reporting and addressing repairs.
Facility staff failed to prime insulin pens before administration for three residents and did not ensure a resident's PT/INR and digoxin levels were obtained as ordered. Staff were unaware of the need to prime insulin pens and had not received training. Additionally, necessary blood test orders were not transcribed into the medical record, potentially leading to incorrect medication dosing.
Facility staff failed to inspect bed frames, mattresses, and bed rails regularly and did not obtain consents or complete assessments for the use of bed rails for three residents. Additionally, a physician's order was not obtained for one resident. Interviews with staff revealed a lack of clarity and adherence to the facility's policy on side rail assessments.
Facility staff failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs of the residents by not providing in-services, re-evaluating, and documenting skills and competencies on a regular basis. The new DON and the administrator revealed that the previous DON, who was responsible for maintaining the in-service binder and ensuring education completion, is no longer with the facility, and no one has been identified to replace them.
A resident with dementia did not receive food in the proper form as per physician's orders. The resident was served regular consistency food instead of a prescribed puree diet due to errors in the diet roster and lack of staff awareness.
Facility staff failed to conduct, document, or create a thorough facility-wide assessment to determine necessary resources for resident care during both day-to-day operations and emergencies. The administrator and DON admitted to the absence of such an assessment and were unaware of its requirement.
Facility staff failed to implement complete policies for water system maintenance to prevent Legionnaire's Disease and did not follow proper hand hygiene and infection control protocols during blood glucose monitoring and insulin administration for two residents. The administrator acknowledged the absence of a water management program, and the LPN admitted to not following proper procedures due to nervousness.
Facility staff failed to document the administration of the pneumococcal vaccine for two residents and the influenza vaccine for two residents. The facility's policies did not include guidelines for these vaccinations, and the DON acknowledged that the vaccination program was not up-to-date in the residents' medical records.
Facility staff failed to develop and implement policies to ensure residents were offered the COVID-19 vaccine and did not document education, offer, or refusal of the vaccine for three residents. The previous Infection Preventionist left, taking all policies and records, and the resident immunization program was not currently underway.
The facility staff failed to maintain an accurate accounting system for resident funds, with missing bank statements for February and March 2023 and incomplete reconciliation for May 2023. The Business Office Manager and new administrator acknowledged issues in managing the resident trust and bond sufficiency.
Facility staff failed to provide timely pain management for a resident with a leg wound, despite the resident's repeated complaints and a documented pain assessment. The facility lacked a specific pain management policy and did not follow protocols for obtaining standing orders for pain control upon admission.
Facility staff failed to assist two residents with transportation to medical appointments. One resident missed neurology consults due to a non-operational transportation van, while another resident missed cancer treatment appointments due to scheduling and transportation issues. The administrator and transportation technicians acknowledged the problems.
Failure to Provide Full-Time Director of Nursing Coverage
Penalty
Summary
Facility staff failed to provide the services of a full-time Director of Nursing (DON) as required for facilities with an average daily occupancy of 60 or more residents. The facility census consistently exceeded 60, with an average daily census of 62. Review of facility records showed that the DON frequently worked as the charge nurse on multiple shifts, including both day and night shifts, instead of fulfilling the full-time administrative responsibilities of the DON role. The facility did not provide a policy for DON coverage, and the Facility Assessment documented the census but did not address the DON's administrative coverage. Interviews with staff and the administrator confirmed that the DON was responsible for scheduling and staffing of nurses, as well as hiring and terminating staff, but was also required to work as a charge nurse due to inadequate staffing levels. The administrator acknowledged ongoing staffing shortages and stated that the DON worked on the floor to ensure nurse coverage. The DON confirmed awareness of the requirement not to serve as a charge nurse when the census is over 60, but stated that staffing shortages necessitated this practice despite ongoing recruitment efforts.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Sexual Abuse Allegation to State Agency
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse between two residents to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe, as mandated by the facility's Abuse and Neglect policy. The policy specifies that any alleged violation involving abuse or resulting in serious bodily injury must be reported immediately, but no later than two hours. The initial allegation involved one resident entering another's room and rubbing lotion on the legs and abdomen, which was reported to the state agency. However, when the allegation changed to include inappropriate touching of the peri area, staff did not report this new information to DHSS. Interviews with facility leadership, including the DON, administrator in training, regional nurse, and interim administrator, revealed that the change in the nature of the allegation was not reported as required. The DON stated that the new allegation was not believed and therefore not reported. Other interviewed staff acknowledged that the policy was not followed and could not explain why the updated allegation was not reported to DHSS within the mandated timeframe.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
Facility staff failed to follow their Abuse and Neglect Policy when they did not investigate an allegation of resident-to-resident sexual abuse. The policy required immediate reporting, investigation, notification of the physician and family, monitoring and documentation of the resident's condition, and revision of the care plan. However, there was no documentation in the medical records of either resident involved regarding the allegation or any actions taken by staff. The resident who made the allegation reported that another resident entered their room at night and engaged in inappropriate touching, and stated that staff did not take the complaint seriously, did not notify their family or physician, and did not initiate an investigation. The resident ultimately contacted law enforcement due to feeling unsafe and unsupported by the facility. Interviews with facility leadership, including the DON, administrator in training, regional nurse, and interim administrator, confirmed that no investigation was conducted after the allegation changed from inappropriate application of soap to sexual assault. The DON admitted to not investigating because they did not believe the allegation, and other leaders acknowledged that the policy was not followed and could not explain why required actions were not taken. Both residents' medical records lacked documentation of the incident or any follow-up, despite the facility's policy outlining specific steps to be taken in such cases.
Misappropriation of Resident Funds by Former Administrator
Penalty
Summary
Facility staff failed to prevent the misappropriation of funds for a resident when the former administrator requested and accepted $800 from the resident's digital wallet service application account into the administrator's personal digital wallet service application account. The resident, who was cognitively intact and did not exhibit behaviors of inattention or disorganized thinking, reported that the money was intended to pay a bill owed to the facility. However, the funds were not applied to the resident's account, and no receipt or statement was provided to the resident. The resident showed evidence of the transaction on their cell phone, indicating that the transfer occurred when the previous owners managed the facility. The former administrator admitted to receiving the funds into their personal account and claimed to have withdrawn the money from a bank, but could not recall which bank or how the cash was applied. The former administrator suggested that the money was given to one of three people in the business office, but no records or receipts were found to confirm this. The facility's former owner's Director of Revenue confirmed that the facility did not receive the money, and the resident was in a Medicaid pending status. The resident's account statements did not reflect the $800 payment, and interviews with the Activity Director and other staff indicated that they did not recall any cash being brought in to pay the resident's bill. The current administrator stated that digital wallet service applications are not appropriate for accepting resident payments and emphasized the need for proper accounting records and receipts.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean floors, windows, and equipment in resident rooms. The report highlights that the facility did not have a policy for staff to report environmental concerns, which contributed to the ongoing issues. Observations on different dates revealed that the floors in various halls and resident rooms were sticky, contained debris, dead bugs, and had black and brown stains. Additionally, some toilets were stained and in disrepair, with residents reporting that their rooms had not been cleaned for extended periods. Interviews with residents revealed dissatisfaction with the cleanliness of their living spaces, with some residents unable to recall the last time their rooms were cleaned. Residents expressed feelings of dirtiness and discomfort due to the lack of regular cleaning. The report also noted that there was often only one housekeeper for the entire building, and on some days, no housekeeper was available. This staffing shortage was confirmed by interviews with housekeeping staff and the facility administrator, who acknowledged the difficulty in maintaining cleanliness due to insufficient staff. The facility's administrator and housekeeping staff admitted to the challenges faced in keeping the environment clean, citing a lack of personnel and the need for additional hiring. The newly appointed Housekeeping Supervisor also acknowledged the poor condition of the facility and expressed a commitment to improving cleanliness once more staff were hired. Despite these acknowledgments, the report indicates that the facility's current state did not meet the standards expected for a safe and homelike environment for residents.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The Dietary Manager (DM) was initially hired as a part-time cook in February 2023 and assumed the DM role in March 2024. However, the DM's personnel record lacked documentation of previous food service experience or food service management certification. The DM admitted to not being a Certified Dietary Manager and having no formal food service training. Additionally, the DM did not receive assistance or consultation from other facility staff. Interviews with the Business Office Manager (BOM) and the administrator revealed that the responsibility for ensuring staff qualifications fell on the administrator. The BOM was unaware of any food service-related training completed by the DM. The administrator acknowledged that the DM should be certified and had instructed the DM to look into certification courses but was unaware of any progress. The administrator, who had only recently started at the facility, admitted to not having had time to address all issues, including the lack of qualified staff in the food and nutrition services department.
Failure to Follow Nutritionally Calculated Menus and Ensure Dietician Review
Penalty
Summary
Facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus. Observations showed that residents on pureed diets did not receive the complete meal as per the menu, missing items like pureed fruit and bread. Additionally, residents on regular diets did not receive bread as specified. The cook admitted to forgetting about the pureed fruit and mentioned that breadsticks were not available, and there was not enough bread for all residents. The Dietary Manager (DM) confirmed that meal substitutions were made without consulting the dietician, and the facility vendor had been out of some items, leading to these substitutions. The DM also admitted to not keeping up with the substitutions log and not knowing when the dietician last reviewed the meals or performed kitchen inspections and staff education. The administrator confirmed that the dietician should come in monthly but had not been seen since the administrator started in March 2024. The administrator also mentioned that food delivery issues had been resolved recently after a delay due to non-payment to the vendor. The facility's Week At a Glance menu was not followed on multiple occasions. On one instance, staff served a hot dog on a bun, cheesy fries, and creamy coleslaw instead of the planned deluxe potato ham bake, mixed vegetables, frosted cake, and dinner roll. The DM signed off on the meal substitution without the dietician's review. Another instance showed that the resident's choice meal was not documented or reviewed by the dietician. The DM could not recall the sides served with the chicken and dumplings meal. On another occasion, staff served cheeseburgers, french fries, baked beans, and cookies instead of the planned roast pork, cornbread stuffing, buttered corn, glazed applesauce cake, and dinner roll. The cook mentioned that the menu was switched due to a missed food delivery. Interviews with staff revealed concerns about food portions and shortages, which were not communicated to the appropriate personnel. The DM admitted to using food from the emergency supply due to insufficient food and mentioned that there were no historical records or documents in the dietary office when they started. The administrator expected kitchen staff to follow prepared menus and the dietician to review any meal substitutions, but these expectations were not met. The administrator also noted that a resident's admission paperwork did not indicate a gluten-free diet, highlighting a lack of communication and documentation within the facility.
Kitchen Cleanliness and Food Safety Deficiencies
Penalty
Summary
Facility staff failed to maintain kitchen cleanliness, leading to potential food contamination. Observations revealed an accumulation of dried food debris on the stand mixer, dust and grease on window exhaust filters and ceiling vents, and ice accumulation in the walk-in freezer. The ice machine's drain line was improperly connected without an air gap, risking cross-contamination. The facility lacked specific cleaning policies for kitchen equipment, and the dietary manager admitted to not discussing kitchen cleaning with maintenance staff, who were responsible for high areas and the ice machine drain. Staff also failed to sanitize kitchen wares properly. Dishwasher G did not fully submerge large pots and pans in the sanitizer solution and did not check the sanitizer concentration, which was found to be less than 150 ppm. The dietary manager confirmed that items should be fully submerged and the sanitizer concentration should be between 200 and 400 ppm. Dishwasher G admitted to not being shown how to use the test strips for checking sanitizer concentration. Additionally, staff did not maintain and serve food at safe temperatures. Cook F pureed spaghetti and green beans and placed them on the steam table without checking their temperatures. The pureed spaghetti and green beans were served at 112°F and 114°F, respectively, well below the required 165°F. The dietary manager confirmed that food temperatures should be checked after pureeing and maintained at 175-180°F on the steam table. The administrator and dietary manager acknowledged their responsibility for kitchen cleanliness and staff training but were unaware of the ice machine drain air gap requirement.
Lack of Operational Policy
Penalty
Summary
The facility administration failed to develop or maintain an operational policy to guide the day-to-day operations of the facility. This deficiency was identified through record reviews and interviews. The facility records lacked a guide for daily functions, and the administrator acknowledged becoming aware of the absence of a policy in the second week of March 2024. The current owners did not leave a policy, and no new policy was developed. The Director of Nursing (DON) confirmed the absence of a policy book, stating that the facility should not be operated without a guiding policy in place. The facility census was 38 at the time of the survey.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
Facility staff failed to implement an Antibiotic Stewardship Program with a system to monitor antibiotic use. The facility, with a census of 38, did not have a policy on antibiotic stewardship, nor did it have a previous record of such a program. The new Infection Preventionist, who recently took over the position, confirmed that there was no antibiotic stewardship program in place and that the previous Infection Preventionist had removed all records and programs upon leaving suddenly. The Director of Nursing corroborated this, stating that all records for the infection prevention program, including the antibiotic stewardship program, were lost when the previous Infection Preventionist left without advance notice. The administrator also confirmed that the new Infection Preventionist had not yet started the antibiotic stewardship program as they were still working on certification.
Failure to Maintain Resident Information Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of residents' personal and medical records by leaving computer screens unattended and visible to others. Observations on multiple occasions showed computer screens with resident information exposed in areas accessible to staff and residents, including a computer kiosk near the dining room and unattended medication carts. Interviews with staff, including a Certified Medication Technician (CMT) and a Certified Nursing Assistant (CNA), confirmed that they were aware of the requirement to close computer screens but failed to do so. The Director of Nursing (DON) also acknowledged that staff are expected to close screens to protect health information privacy.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
Facility staff failed to provide a sanitary, comfortable, and homelike environment in the 200 hallway spa/shower room and the 100 hall. Observations revealed a bathtub filled with fall mats, wheelchair cushions, and wheelchair pedals, along with loose and missing baseboards on two walls. Additionally, multiple resident rooms were found with various issues such as strong odors of urine, damaged sheet rock, stained floors, missing wall trim, and debris on the floor. The facility census was 38 at the time of the survey. Interviews with staff indicated a lack of a full-time maintenance department and an absence of a clear process for reporting and addressing environmental repairs. Housekeeping staff reported continuous cleaning efforts but acknowledged the presence of debris and stains. Certified Nurse Aides confirmed the inappropriate storage of items in the spa room and the lack of a maintenance worker to address repairs. The administrator admitted to the absence of a process for ensuring facility repairs and the lack of a full-time maintenance supervisor, although efforts were being made to build a communication process for reporting issues.
Failure to Prime Insulin Pens and Ensure Blood Test Orders
Penalty
Summary
Facility staff failed to meet professional standards of quality by not priming insulin pens before administration for three residents. Observations showed that both an LPN and an RN administered insulin without priming the pens, which is necessary to remove air bubbles and ensure accurate dosing. The staff members involved were unaware of the need to prime the pens and had not received training on insulin pen usage at the facility. The Medical Director and the pharmacist confirmed that failing to prime the pens could result in incorrect insulin dosing, potentially affecting resident health. Additionally, the facility failed to ensure that a resident's Prothrombin and International Normalized Ratio (PT/INR) and digoxin levels were obtained as ordered. The resident had a diagnosis of atrial fibrillation and was prescribed warfarin and digoxin, but the Physician Order Sheet did not contain orders for the necessary blood tests. Interviews with the Medical Director and nursing staff revealed that the orders were not transcribed into the medical record, which could lead to incorrect medication dosing. The Director of Nursing acknowledged that the facility lacked policies for insulin pen usage and physician orders. The DON admitted that periodic checks of physician orders had not been conducted, as they were new to the role. The failure to prime insulin pens and ensure proper blood test orders were in place highlights significant gaps in staff training and policy implementation at the facility.
Failure to Complete Bed Rail Assessments and Obtain Consents
Penalty
Summary
Facility staff failed to complete the inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to ensure bed rails/grab bars were properly secured. Additionally, the facility did not obtain consents for the use of bed rails for three residents and failed to obtain a physician's order for one resident. The facility also did not complete bed rail use assessments for two residents. These deficiencies were identified through observation, interview, and record review during the survey process. The facility's policy on side rails, dated 01/23/23, outlines specific procedures for the use of side rails, including assessments, consents, and entrapment assessments, which were not followed in these cases. Resident #6, who was cognitively intact and required substantial assistance for mobility, had side rail assist bars without a completed side rail assessment, consent, or entrapment assessment. Resident #12, who was moderately cognitively impaired and dependent on staff for mobility, had a U-Bar in the upright position without a completed side rail assessment, physician order, consent, or entrapment assessment. Resident #33, who was cognitively intact and required supervision for transfers, also had side rail assist bars without a signed consent or entrapment assessment. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed a lack of clarity and adherence to the facility's policy on side rail assessments and entrapment assessments.
Failure to Ensure Nursing Staff Competencies
Penalty
Summary
Facility staff failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs of the residents by not providing in-services, re-evaluating, and documenting skills and competencies on a regular basis. The facility's policies did not include a policy on staff annual education or in-service requirements. The in-service annual training documentation did not contain evidence of skills and competencies to meet the care needs of the residents. During interviews, the new Director of Nursing (DON) and the administrator revealed that the previous DON, who was responsible for maintaining the in-service binder and ensuring education completion, is no longer with the facility, and no one has been identified to replace them. The facility census was 38.
Failure to Provide Proper Diet Consistency
Penalty
Summary
The facility failed to ensure that a resident received food in the proper form according to their physician's orders. Resident #13, who was cognitively impaired with a diagnosis of dementia, had a physician's order for a puree texture, regular/thin consistency diet. However, the resident's care plan did not contain direction for diet consistency, and the diet roster listed the resident's diet type as regular diet and regular texture. On observation, the resident was served regular consistency spaghetti and green beans, contrary to the prescribed puree diet. The slip of paper with the resident's diet order was crossed out and incorrectly indicated a regular diet and consistency. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary needs. The CNA assisting the resident was unaware of the puree diet until the day after the observation. The cook followed the incorrect ticket provided and was unaware of the resident's actual dietary requirements. The Dietary Manager acknowledged the error and indicated that the cook was responsible for ensuring the correct meal texture. The Dietary Manager also mentioned difficulties in managing diet orders due to recent access to the dining software and the need to print diet rosters periodically to review diets.
Failure to Conduct Facility-Wide Assessment
Penalty
Summary
Facility staff failed to conduct, document, or create a thorough facility-wide assessment to determine the necessary resources for resident care during both day-to-day operations and emergencies. The facility census was 38. Record review showed no policy or guidance for developing a facility assessment. During an interview, the administrator admitted that there was no facility assessment and was unaware of the requirement. The Director of Nursing also confirmed the absence of a facility assessment and acknowledged its importance for proper facility operation.
Inadequate Infection Control and Water Management Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water system to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease. The administrator acknowledged the absence of a water management program, despite being aware of the requirement. The facility's Water Management Program policy was undated, and the administrator, who started on 03/01/24, could not locate the water management plan. Additionally, the facility did not provide policies on hand hygiene, infection control, blood glucose testing, or insulin administration. During an observation, an LPN failed to use appropriate hand hygiene during blood glucose monitoring and insulin administration for two residents. The LPN did not wear gloves during insulin administration for one resident and did not cleanse the glucometer between uses for two residents. The LPN admitted to knowing the proper procedures but failed to follow them due to nervousness. The Director of Nursing confirmed that staff are expected to wash their hands before and after performing blood glucose tests, wear gloves when administering insulin, and clean the blood glucose meter between each resident. The failure to adhere to these protocols could result in the spread of bacteria or infection to staff or other residents.
Failure to Document Vaccinations
Penalty
Summary
Facility staff failed to document the administration of the pneumococcal vaccine for two residents and the influenza vaccine for two residents out of six sampled residents. Specifically, Resident #4, aged 81, admitted on 03/12/15, did not have documentation of receiving or refusing the pneumococcal vaccine. Resident #35, aged 69, admitted on an unspecified date, did not have documentation of receiving or refusing both the pneumococcal and influenza vaccines. Resident #37, admitted on an unspecified date, did not have documentation of receiving or refusing the influenza vaccine. The facility's policies did not include guidelines for pneumococcal or influenza vaccinations. Interviews with the Infection Preventionist and the Director of Nursing (DON) revealed that both believed the immunization information for residents was up to date and that a system was in place. However, the DON, who was responsible for the vaccination program, acknowledged that the program was not up-to-date in the residents' medical records.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
Facility staff failed to develop and implement policies and procedures to ensure each resident was offered the COVID-19 vaccine. The facility did not document that residents or their representatives were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. Additionally, the facility did not document each dose of the COVID-19 vaccine administered to the residents or if the residents did not receive the vaccine due to medical contraindications or refusal. This deficiency was identified for three residents out of six sampled residents, with a facility census of 38. Resident #4's medical record showed that the resident received one dose of the COVID-19 vaccine but lacked documentation of education, refusal, or offer of the second dose or an updated booster. Resident #35 and Resident #37's medical records did not contain any documentation of education, offer, or refusal of the COVID-19 vaccine. Interviews with the Infection Preventionist and the Director of Nursing confirmed that all COVID-19 vaccination documentation should be in the residents' electronic medical records, but this was not the case. The administrator mentioned that the previous Infection Preventionist had left the position and took all policies and records, and the resident immunization program was not currently underway.
Failure to Maintain Accurate Accounting System for Resident Funds
Penalty
Summary
The facility staff failed to maintain an accurate accounting system for resident funds, as evidenced by discrepancies in the reconciliation of bank statements for February 2023, March 2023, and May 2023. Specifically, the facility did not provide a policy for resident funds, reconciliation of resident funds, or a surety bond. The accounting records for February and March 2023 lacked corresponding bank statements, and the May 2023 reconciliation did not include a final total showing outstanding deposits and withdrawals. This issue had the potential to affect all residents with funds entrusted to the facility, with a census of 38 residents at the time of the survey. During interviews, the Business Office Manager (BOM) admitted to difficulties in obtaining bank statements from the prior company and acknowledged that the issue was not followed up after informing the previous administrator. The BOM also revealed a lack of awareness regarding incomplete calculations in the May 2023 reconciliation and uncertainty about how to use reconciled amounts to calculate the bond. The new administrator, who had been relying on the BOM to manage the resident trust, indicated plans to train a new staff member and provide oversight for monthly reconciliations and bond sufficiency. However, no review of the bond or its coverage of patient funds had been conducted since the prior administrator's departure.
Failure to Provide Appropriate Pain Management
Penalty
Summary
Facility staff failed to provide appropriate pain management interventions for a resident with a leg wound. The resident, who was admitted to the facility with a diagnosis of a leg wound, did not have a documented baseline care plan that included pain interventions. Despite the resident's complaints of pain and a pain assessment indicating a history of pain and a current pain level of four on a 1-10 scale, staff did not provide timely pain relief. Nurse notes from 04/01/24 to 04/04/24 showed that the resident's pain was acknowledged but not adequately addressed, with no interventions documented until new orders for Tramadol were received on 04/04/24. Interviews with the resident and staff revealed that the resident repeatedly requested pain medication but did not receive it in a timely manner. The medical director and nursing staff indicated that standing orders for pain control should be obtained upon admission, and pain complaints should prompt immediate action, including contacting the physician for further orders. However, these protocols were not followed, resulting in the resident experiencing unmanaged pain for several days. The facility also lacked a specific policy for pain management or baseline care plans, contributing to the deficiency in care.
Failure to Assist Residents with Transportation to Medical Appointments
Penalty
Summary
Facility staff failed to assist two residents with transportation arrangements to and from their medical appointments. Resident #33, who is cognitively intact and diagnosed with migraine headaches, had orders for a neurology consult dating back to August and December of the previous year. Despite these orders, the resident reported that the facility did not ensure transportation to the neurology appointments. Interviews with the transportation technicians revealed that the facility's transportation van was out of service for several months, and there were delays in setting up appointments due to authorization issues from the primary care provider. The prior transportation technician confirmed that the transportation van was non-operational for six to eight months, and the administrator was informed of the transportation needs during that period. Resident #35, also cognitively intact and diagnosed with a malignant neoplasm of the connective and soft tissue, had multiple appointments for cancer treatment that were either missed or canceled by the facility. The resident expressed significant concern about the delays in treatment. The scheduling assistant for the oncologist confirmed that appointments were missed or canceled due to transportation issues, including a lack of available transportation slots and the transportation bus being held up. The Director of Nursing was unsure why the appointments were canceled, stating that transportation priorities were decided by the administrator. The administrator acknowledged the transportation issues and cited unexpected problems that prevented planned transportation to the appointments.
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 48 citations issued within 25 miles in the last 12 months — 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) |
|---|---|---|---|---|
| Aspire Senior Living New Florence | 12.3 mi | ★★★★★ | 18 | 0 |
| Baptist Homes, Tri-county | 16.7 mi | ★★★★★ | 0 | 0 |
| Pin Oaks Living Center | 19.6 mi | ★★★★★ | 9 | 0 |
| Aspire Senior Living Jonesburg | 20.7 mi | ★★★★★ | 19 | 0 |
| Fulton Manor Care Center | 24.6 mi | ★★★★★ | 2 | 0 |
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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.