Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Maple Manor Rehab Center during CMS and state inspections, most recent first.
A resident who developed a pressure ulcer did not have their care plan updated to reflect the wound or the prescribed interventions, despite documented recommendations from a Wound Care Practitioner for specific treatments and preventive measures. The care plan remained outdated and did not address the current skin impairment, and staff confirmed that the necessary updates were missed.
Two residents who required assistance with ADLs were observed with unkempt facial hair and long, dirty fingernails due to staff failing to provide routine shaving and nail care as required by care plans and facility policy. Both residents had intact cognition and expressed a desire for proper hygiene, but staff did not ensure these services were completed or documented, resulting in unmet hygiene needs.
A resident did not receive appropriate care for pressure ulcers, and preventive measures were not consistently implemented to avoid the development of new ulcers. Surveyors observed lapses in pressure ulcer management and insufficient monitoring for residents at risk.
A resident with a urinary tract infection and a supra-pubic catheter received a prescribed course of Macrobid, but their antibiotic use was not recorded on the facility's antibiotic surveillance log. This omission led to inaccurate infection rate calculations for several months, despite facility policy requiring all infections to be tracked and an antibiotic stewardship program to be in place.
A resident with Alzheimer's disease, who had provided consent along with their legal guardian for influenza and pneumococcal vaccines, did not receive either immunization despite being eligible and screened. The Infection Preventionist confirmed the oversight, and there was no documentation of vaccine administration in the medical record, contrary to facility policy.
A resident with Alzheimer's disease who had consented to receive the COVID-19 vaccine did not receive it, despite being screened and found eligible. The facility's Infection Preventionist confirmed that the vaccine was missed and that facility policy required vaccination upon admission.
A resident was discharged with heparin and syringes without proper education on administration, despite having a history of traumatic brain injury. The care plan noted a risk for complications, but no pre-discharge plan was established. Nurse B followed the NP's order to send the resident home with the medication, but did not provide training due to the resident's eagerness to leave. The facility's discharge policy was not followed, as the medication was not included in the discharge instructions.
The facility failed to maintain food safety standards, with undated and expired food found in the kitchen and resident refrigerators. Observations revealed moldy and rotten items, as well as staff personal food improperly stored. The Dietary Manager, CNA, RN, and administration acknowledged the need for proper labeling and removal of expired items to prevent foodborne illness.
The facility's Infection Control Program was found lacking, as the Infection Preventionist did not have a list of reportable diseases and failed to track staff illness call-ins. Additionally, the microbiology summary report, essential for monitoring antibiotic use, was unavailable and not discussed in meetings, indicating a failure to implement the facility's policies on infection surveillance and antibiotic stewardship.
A facility failed to assess a resident for self-medication administration before leaving medications at the bedside. The resident, with multiple diagnoses and a BIMS score indicating cognitive intactness, was observed during medication administration. A nurse left a Lidocaine Patch and a breathing treatment at the resident's bedside without verifying a physician's order for self-administration or bedside medication storage. The medical record lacked a physician's order for self-administration, and the resident's plan of care did not include information on the capacity to self-administer medication.
A facility failed to secure a resident's protected health information, leaving it visible on an unlocked computer screen in a common area. A CNA admitted to not logging off, and the DON confirmed the need for confidentiality. Additionally, a resident was without a privacy curtain for an extended period, leading to dissatisfaction. The Maintenance Director cited staffing issues for the delay, and the DON agreed on the necessity of privacy curtains.
A resident with multiple health conditions, including cerebral palsy and depression, was not consistently assisted with shaving, as required by the facility's care protocols. Despite being scheduled for showers twice a week, records showed that shaving was not performed or documented regularly. Staff interviews confirmed the inconsistency, and the Interim DON could not explain the oversight.
A resident receiving hospice services at the facility was not provided with a clear schedule or documentation of hospice care. The resident's hospice notebook lacked a current calendar and details of services, and there was no evidence of care conference collaboration with hospice providers. The Interim-DON confirmed the hospice care plan was incomplete.
Failure to Update Care Plan for Pressure Ulcer and Prescribed Interventions
Penalty
Summary
The facility failed to update the care plan for a resident who developed a pressure ulcer while residing in the facility. Observation revealed the resident was awake, alert, and sitting up in bed with some confusion, and had a dime-sized, shallow, crater-like open area on the coccyx covered with dried white cream. The CNA reported the pressure ulcer had developed a couple of weeks prior and that a cream was being applied. The RN confirmed the pressure ulcer was facility-acquired and, upon review of the electronic health record, could not find documentation of a care plan addressing the pressure ulcer. The most recent care plan for skin integrity, last reviewed months earlier, only included a goal for the skin to remain free from breakdown and did not reflect the current skin impairment or prescribed interventions. Progress notes from the Wound Care Practitioner documented the presence of moisture-associated skin damage and a small open area at the coccyx, with specific recommendations for wound care, pressure relief, and dietary interventions. These recommendations included the use of zinc oxide cream, a dry bulky dressing, aggressive off-loading, a foam wedge, a low-air-loss mattress, off-loading heel boots, and a dietitian consult. However, these interventions were not incorporated into the resident's care plan. The Director of Nursing acknowledged that the orders and recommendations were missed and the care plan was not updated, contrary to the facility's policy requiring the interdisciplinary team to develop a relevant care plan after assessment.
Failure to Provide Adequate ADL Assistance for Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who were unable to perform these tasks independently. One resident was repeatedly observed with long, dirty, and untrimmed fingernails as well as unkempt facial hair. The resident confirmed not being offered shaving or nail care, even on scheduled shower days, and expressed a desire for these services, noting that prior to admission, facial hair was kept neat. The care plan indicated the resident required assistance with all ADLs due to generalized weakness, but staff did not ensure the resident was added to the barber list or provided with nail care. Both the unit manager and DON acknowledged that CNAs and nurses were responsible for providing and verifying completion of these ADL tasks on shower days, but this was not done. Another resident was observed multiple times with long fingernails containing visible debris and reported being unable to cut their own nails, preferring them short. The resident's medical record showed a diagnosis of cerebral palsy and a need for substantial to maximal assistance with ADLs, with no documentation of refusals for care. The care plan lacked specific interventions for nail care, and staff interviews confirmed that nails should be trimmed and cleaned according to resident preferences. Facility policy required routine cleaning and inspection of nails during ADL care, but this was not consistently implemented, resulting in the residents' unkempt appearance.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and review of care practices, indicating that residents did not consistently receive the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The report notes lapses in the implementation of pressure ulcer prevention protocols and inadequate monitoring of residents at risk for skin breakdown.
Failure to Accurately Record Antibiotic Use on Surveillance Log
Penalty
Summary
The facility failed to accurately record the use of antibiotics for one resident on the antibiotic surveillance log. The resident, who was admitted with urinary retention and required a supra-pubic catheter, was diagnosed with a urinary tract infection and prescribed Macrobid 100 mg twice daily for 7 days, followed by Macrobid 50 mg once daily for 90 days. Review of the Medication Administration Record confirmed that the resident received the prescribed antibiotics from March through June, but the facility's Infection Control Log did not include the resident's use of Macrobid 50 mg once daily during this period. During an interview, the Infection Preventionist acknowledged that the resident's antibiotic use was overlooked and not included in the facility's antibiotic surveillance log or infection rate calculations for April, May, and June. This omission resulted in an incorrect facility infection rate for those months. The facility's policies require that all resident infections be tracked and that an antibiotic stewardship program be implemented as part of the infection prevention and control program.
Failure to Administer Consented Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide influenza and pneumococcal immunizations to one resident who had both the capacity and consent, as well as legal guardian consent, to receive these vaccines. The resident, who had Alzheimer's disease, was admitted to the facility and was screened and determined eligible for both vaccines. Despite signed and dated consents for both immunizations in January 2025, there was no documentation that either vaccine was administered. The Infection Preventionist confirmed that the vaccines were not given and acknowledged the oversight, stating that the resident should have received them. Facility policy required that influenza vaccines be offered annually between October 1st and March 31st, and that pneumococcal vaccines be offered unless medically contraindicated or previously administered, with completed records to be filed in the medical record.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to provide the COVID-19 vaccine to one resident who had consented to receive it, as identified through interview and record review. The resident, who had a diagnosis of Alzheimer's disease, was admitted to the facility and, along with their legal guardian, signed a consent form for the COVID-19 vaccine in January 2025. Despite being screened and determined eligible for vaccination, there was no documentation that the vaccine was administered. The Infection Preventionist confirmed that the facility's policy required screening, education, and provision of the COVID-19 vaccine upon admission, but acknowledged that the vaccine was missed for this resident without excuse. This deficiency was identified during a review of the facility's Infection Prevention Control Program and the resident's electronic health record, which showed a lack of documentation for the COVID-19 vaccine despite completed consent and eligibility.
Inadequate Discharge Planning for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure adequate discharge planning for a resident, identified as R400, who was discharged with a bottle of heparin and syringes without proper education on administration. The resident, who had a history of traumatic brain injury and other medical conditions, was not previously on this medication. The hospital social worker reported that the resident was discharged without any explanation on how to use the medication, which is typically administered by a nurse. The resident's care plan indicated a risk for complications related to anticoagulant therapy, but there was no evidence of a pre-discharge plan being established with the resident or their representatives. The progress notes from the day of discharge did not include any instructions on the anticoagulant, and the discharge instructions provided to the resident did not mention the medication or how to administer it. Nurse B, who was involved in the discharge, admitted to not providing training on the medication due to the resident's eagerness to leave and later updated the progress note to reflect the discontinuation of heparin, which was not initially documented. Interviews with facility staff revealed that Nurse B was following the Nurse Practitioner's order to send the resident home with the anticoagulant if they were not walking. However, Nurse B expressed discomfort with this decision, fearing potential bleeding complications. The Director of Nursing confirmed that Nurse B was following the NP's order. The facility's policy on discharge summary required reconciliation of medications and documentation of discharge instructions, which was not adhered to in this case.
Deficient Food Safety Practices in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to maintain proper food safety standards in the kitchen and resident refrigerators, as observed during a survey. In the kitchen walk-in cooler, there were undated and moldy food items, including bell peppers and mixed salad, as well as a tub of white onions and a box of sour cream without expiration dates. The kitchen freezer contained a staff member's personal item, a frozen bottle of red pop, which was not supposed to be there. In the pantry, an opened bottle of honey was found with an expired date. The Dietary Manager acknowledged that all items should be labeled, dated, and expired items discarded. Further observations in the North and South unit resident refrigerators revealed numerous unlabeled and undated food items, including personal staff lunches, drinks, and expired food items such as a rotted orange and expired frozen yogurts. Both the Certified Nursing Assistant and Registered Nurse present during the observations agreed that staff food should not be stored in resident refrigerators and that all items should be labeled and expired food removed. The Nursing Home Administrator and Director of Nursing were unsure of which department was responsible for maintaining the unit refrigerators, but agreed with the need for proper labeling and removal of expired food to prevent foodborne illness. The facility's policies on food safety and storage were reviewed, highlighting the requirement for labeling, dating, and monitoring refrigerated food.
Inadequate Infection Control Program and Surveillance
Penalty
Summary
The facility failed to establish a comprehensive Infection Control Program, as evidenced by several deficiencies noted during a review with the Infection Preventionist (IP) and the Interim Director of Nursing (I-DON). The IP was unable to provide a list of diseases that are required to be reported to state and local health departments. Additionally, the IP did not review or track the staff call-in log, which documents reasons for staff absences, including illness. This lack of documentation and tracking could hinder the facility's ability to monitor potential infection outbreaks among staff and residents. Furthermore, the facility did not have the microbiology summary report available, which is crucial for monitoring antibiotic usage and preventing overuse or inappropriate use. The report, which includes results of cultures and antibiotic susceptibility patterns, was not received or discussed during infection control meetings, as confirmed by the Medical Director. The facility's policies on Antibiotic Stewardship and Infection Surveillance were not effectively implemented, as they require tracking of employee infections and utilization of data from staff reports of symptoms, which was not being done.
Failure to Assess Resident for Self-Medication Administration
Penalty
Summary
The facility failed to assess a resident for self-medication administration before leaving medications at the bedside. The resident, who was admitted with multiple diagnoses including congestive heart failure, hypertension, and COPD, was observed during medication administration. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. During the observation, a registered nurse left a Lidocaine Patch and a breathing treatment at the resident's bedside upon the resident's request, without verifying a physician's order for self-administration or bedside medication storage. The medical record review revealed no physician's order for the resident to self-administer medication or to keep medication at the bedside. Additionally, the resident's plan of care did not include any information on the capacity to self-administer medication. An evaluation for self-administration of medication indicated the resident preferred to use the facility's nursing services, and the section for self-administration was left blank. The Interim-DON confirmed the lack of a physician's order and the absence of a completed evaluation demonstrating the resident's capability or desire to self-administer medication.
Privacy and Confidentiality Deficiencies in Resident Care
Penalty
Summary
The facility failed to properly secure protected health information for a resident, resulting in the potential for unauthorized disclosure, access, and modification. During an observation, a hallway computer screen was found unlocked with the electronic health record of a resident visible to multiple staff and visitors. A Certified Nursing Assistant (CNA) was logged into the computer and admitted to leaving the screen unlocked to answer a call, acknowledging the mistake of not logging off. The Director of Nursing confirmed that staff should log out or close the screen when leaving an EHR screen to protect confidential patient information. Additionally, the facility failed to provide a privacy curtain for a resident, leading to dissatisfaction and a lack of privacy. The resident expressed concern about the absence of a privacy curtain, which was confirmed by observations over two days. The Maintenance Director acknowledged receiving a work order for the curtain two weeks prior but had not completed the installation due to staffing issues. The Director of Nursing agreed that each resident bed should have a privacy curtain to maintain privacy. The facility's policy on confidentiality emphasizes the right to secure and confidential personal and medical records.
Failure to Provide Consistent ADL Assistance for Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a resident who was dependent on staff for personal care. The resident, who was admitted with multiple diagnoses including athetoid cerebral palsy, hypertension, and major depression, was observed with facial hair stubble on multiple occasions, indicating a lack of regular shaving. The resident expressed a desire to be shaved and noted that staff only assisted with shaving sporadically. The facility's policy was to shave male residents on the days they received showers, but records showed that shaving was not consistently documented or performed. Interviews with staff, including a Certified Nursing Aide (CNA) and the Interim Director of Nursing (DON), confirmed that the resident was scheduled for showers twice a week, during which shaving was supposed to occur. However, documentation revealed that shaving was not completed or recorded on several occasions. The Interim DON acknowledged the lack of documentation and was unable to provide an explanation for the oversight. This deficiency in care was observed and confirmed during the surveyor's visit, highlighting a failure to adhere to the facility's care protocols for dependent residents.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to coordinate hospice services for a resident, resulting in a deficiency. The resident, who was admitted with multiple diagnoses including a benign neoplasm of the left kidney, type 2 diabetes, and chronic obstructive pulmonary disease, was receiving hospice services. However, the resident was unable to explain the disciplines or frequency of the hospice services provided and did not have a visible hospice service calendar in their room. The resident's medical record indicated they were receiving hospice services, but the plan of care did not specify the frequency or schedule of these services. During interviews, it was revealed that the hospice information, including a calendar of visits and services, should have been documented in a hospice notebook at the nurse's station. However, the notebook for the resident contained a blank hospice calendar and lacked details on the services and their schedule. The Interim-Director of Nursing confirmed the absence of a current hospice calendar and acknowledged that the hospice care plan was incomplete. Additionally, there was no documentation of care conference collaboration with hospice services, indicating a lack of coordination and communication between the facility and hospice providers.
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 1,018 citations issued within 25 miles in the last 12 months — including the 6 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 Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Wayne | 0.2 mi | ★★★★★ | 10 | 0 |
| Pine Creek Manor Skilled Nursing & Rehab Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Imperial, A Villa Center | 3.3 mi | ★★★★★ | 10 | 1 |
| Cherry Hill For Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 13 | 0 |
| Regency At Westland | 3.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maple Manor Rehab Center.
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.