Cycle 1
Health 2024-09-12 · Fire 2024-09-12
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Johnstown, NY
Wells Nursing Home Inc
1-star overall rating with 2-star inspections with abuse icon flag with $8,512 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
201 W Madison Avenue, Johnstown, NY
(518) 762-4546
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
88
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-01-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,271
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9983
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.82
Performance 21.05% · Measure score 0.82 · Achievement 0.82 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.90
Baseline 5.42% · Performance 6.67% · Measure score 3.90 · Achievement 3.90 · Improvement 0
Total nurse turnover
9.38
Baseline 14.29% · Performance 25.33% · Measure score 9.38 · Achievement 9.38 · Improvement 0
Adjusted total nurse staffing
3.95
Baseline 4.09 hours · Performance 4.20 hours · Measure score 3.95 · Achievement 3.95 · Improvement 0.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 5.73% |
| Discharge to community | 42.18% |
50.57%
8.4 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 34.04% · Lower 95% interval 32.61% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 66.67% |
95.27%
28.6 pts worse
|
Numerator 26 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 48.39% |
53.69%
5.3 pts worse
|
Numerator 15 · Denominator 31 |
| Discharge mobility score | 64.52% |
50.94%
13.6 pts better
|
Numerator 20 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 2 · Denominator 39 · Adjusted rate 3.71% |
| Healthcare-associated infections requiring hospitalization | 6.67% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 4.64% |
8.2%
3.6 pts worse
|
Numerator 7 · Denominator 151 |
| Staff flu vaccination coverage | 66.1% |
42%
24.1 pts better
|
Numerator 117 · Denominator 177 |
| Discharge function score | 54.84% |
56.45%
1.6 pts worse
|
Numerator 17 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 11 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
91.2%
6.6 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 91.4% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
95.3%
1.1 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.0%
2.6 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 2.5% · Q3 5.1% · Q4 6.2% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.1%
0.5 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 13.2% · Q3 3.1% · Q4 3.8% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
13.5%
8.2 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 22.1% · Q3 19.5% · Q4 19.8% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.8% |
14.8%
18 pts worse
|
16.7%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 37.3% · Q3 29.0% · Q4 27.9% · 4Q avg 32.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.7% |
15.1%
0.4 pts better
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 11.0% · Q3 9.1% · Q4 14.3% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
15.5%
0.4 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 13.6% · Q3 13.4% · Q4 12.3% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.2% |
0.6%
3.6 pts worse
|
1.0%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.1% · Q3 4.4% · Q4 2.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.0% |
1.4%
3.6 pts worse
|
1.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.3% · Q3 3.8% · Q4 6.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.7% |
20.8%
14.9 pts worse
|
19.8%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 32.1% · Q3 40.9% · Q4 36.9% · 4Q avg 35.7% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.9%
2.3 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 1.3% · Q3 4.2% · Q4 7.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
76.7%
8.4 pts better
|
81.7%
3.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.9% · Q3 98.4% · Q4 61.1% · 4Q avg 85.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
9.7%
6.5 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 15.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
78.8%
13.2 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.1% |
20.6%
4.5 pts better
|
23.9%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 15.0% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-27 · Fire 2021-10-27
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2019-05-09 · Fire 2019-05-09
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-12
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-08
F · Potential for more than minimal harm
2021-10-27
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-10-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-12-26
D · Potential for more than minimal harm
2019-05-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-07-18
D · Potential for more than minimal harm
2019-05-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2019-07-08
Inspection history
Recent health citations
G · Actual harm
2024-09-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-09-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-09
E · Potential for more than minimal harm
2021-10-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-12-26
E · Potential for more than minimal harm
2019-05-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-07-08
E · Potential for more than minimal harm
2019-05-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-07-08
E · Potential for more than minimal harm
2019-05-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-07-08
E · Potential for more than minimal harm
2019-05-09
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-07-15
D · Potential for more than minimal harm
2019-05-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2019-07-08
Penalties and ownership
What sits behind the stars
$8,512
2024-09-12
Fine
Fine · fine $8,512
Fine
Ownership
Bartholomew, Carol
Corporate Director · Individual
Campos, Anne
Corporate Director · Individual
Kline, George
Corporate Director · Individual
Mccoski, William
W-2 Managing Employee · Individual
Mcnamara, Peter
Corporate Director · Individual
Reppenhagen, Maryann
W-2 Managing Employee · Individual
Sitterly, Jane
Corporate Director · Individual
Slingerland, Sara
Corporate Director · Individual
Smith, Peter
Corporate Director · Individual
Thompson, Barbara
W-2 Managing Employee · Individual
Vangorder, Dee Dee
W-2 Managing Employee · Individual
Vanslyke, Neal
W-2 Managing Employee · Individual
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#3
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