Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Wayne Countryview Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and severe cognitive impairment was rated low risk for wandering, but after attempting to open an exit door, the resident was not reassessed and no new elopement interventions were documented. The facility also had multiple resident room sinks with water temperatures above the 120-degree standard, including several rooms occupied by residents able to use their bathrooms independently. The DON and Operations Manager confirmed the temperatures were too hot to ensure resident safety.
A facility failed to complete a comprehensive discharge summary for one resident, including a recapitulation of care and medication reconciliation, after transfer to an acute care hospital. The facility also failed to notify the State Ombudsman of the discharges for two residents, including one discharged to the hospital and one discharged home; the DON and Social Services Director confirmed the omissions.
Delayed assistance with meals: Two residents with severe cognitive impairment and documented need for substantial eating assistance were left without timely cueing or help during breakfast. One resident with Alzheimer’s dementia and malnutrition was seated with a meal tray but was not assisted with setup or eating, and the meal remained uncovered while the resident ate only one bite. Another resident with dementia, HF, and depression received only brief help with one drink before staff left, and total feeding assistance was not provided until more than an hour after the meal was served.
A resident with dementia, malnutrition, CAD, and HTN had significant weight fluctuations and consistently poor meal intake, averaging about 50%, while staff failed to provide timely feeding assistance and meal setup. The resident’s nutritional supplement order was delayed after repeated faxes to the PCP, and during observation the resident was left without effective cueing or assistance, with food left uncovered and uneaten. Meal intake documentation was also missing on multiple days.
Hand hygiene and PPE were not used appropriately during care for a resident on EBP with an indwelling urinary catheter. A nurse aide transferred the resident, emptied the catheter bag, and handled the catheter and clothing without completing hand hygiene at required points and without wearing a gown and gloves for all indicated direct care activities; the aide and DON confirmed the resident should have had gown-and-glove use for transfers and catheter care.
The facility failed to employ a qualified Dietary Manager, as the current DM had not completed the required training or education. This deficiency was confirmed through interviews with the DM and the facility Administrator, highlighting a potential impact on the quality of nutritional services provided to residents.
The facility failed to maintain kitchen cleanliness and proper food temperatures, risking foodborne illness for residents. Observations revealed dirty floors, caked-on food, and improper food temperatures. The ice machine was also inadequately maintained, with the last cleaning occurring three months prior. Interviews confirmed lapses in daily cleaning and temperature recording.
The facility failed to implement required PPE during care for residents with infections, did not have a waterborne illness mitigation plan, and neglected proper hand hygiene during medication administration and meal delivery. A resident with VRE and another with a surgical wound did not receive care with appropriate PPE. Additionally, staff did not follow hand hygiene protocols, risking cross-contamination.
The facility was found to have multiple deficiencies in maintaining a clean and homelike environment, including stained ceiling tiles, chipped drywall, soiled carpets, and chipped paint. Additionally, issues such as unsecured floor drain caps, dust-coated filters, and damaged flooring were observed. The facility Administrator confirmed these concerns required repair, noting that the previous Maintenance Supervisor had removed work orders without completing repairs.
A facility failed to maintain a pest-free environment, with tiny black bugs found in a resident's bathroom and dead spiders in the kitchen. Despite having a pest control policy and contract, observations confirmed unclean conditions, and staff interviews revealed that kitchen windows and screens had not been cleaned. The administrator acknowledged the issue, leading to the relocation of the affected resident.
A resident with multiple health conditions and moderate cognitive impairment was found with Tums antacid tablets in their bathroom without a physician's order or an assessment for self-administration competency. The facility failed to follow its policy and state regulations regarding the evaluation and documentation of self-administration of medications.
A resident with severe cognitive impairment and incontinence was not provided timely toileting assistance, contrary to the facility's policy requiring checks every 2-3 hours. Observations showed the resident with strong odors of feces and urine, and staff confirmed a delay of over four hours in providing necessary care.
A facility failed to follow a physician's order for a resident's fluid restriction, as there was no documentation of monitoring intake and output. Observations showed the resident had access to a full water pitcher, contrary to the order. The DON confirmed the oversight and the responsibility of Charge Nurses to document intake and output.
A facility failed to monitor a dialysis access site for a resident requiring dialysis services. The facility's policy requires checking the access site for condition, bruit, and thrill every shift, and notifying a physician of any complications. Despite the resident's orders for dialysis three times a week, there was no evidence in the medical records that the nursing staff monitored the access site. An LPN confirmed the requirement to assess the site but acknowledged the lack of evidence for completed assessments.
The facility failed to label insulin pens with an open date for two residents, as required by their policy. Observations revealed that insulin pens for these residents lacked the necessary documentation, which was confirmed by the RN and acknowledged by the DON and Administrator.
Failure to Reassess Elopement Risk and Control Unsafe Water Temperatures
Penalty
Summary
The facility failed to reassess and implement interventions to prevent a potential elopement for a resident with Alzheimer's disease, severe cognitive impairment, and a history of rejection of care, incontinence, and falls. The resident's MDS dated 11/24/25 showed substantial to maximal assistance needs for dressing, bathing, personal hygiene, bed mobility, and transfers. An elopement/wandering evaluation dated 12/8/25 rated the resident as low risk, but the resident later attempted to open a door on the 300 hall and was found at an open door before being redirected back to the commons area. The medical record contained no evidence that the resident's elopement risk was reassessed or that interventions were developed after this event. The facility also failed to prevent the potential for burns from hot water temperatures in resident handwashing sinks. Review of the facility's water temperature policy showed staff were to test water temperatures, but the policy did not identify an acceptable temperature or how often checks were to be performed. Surveyor measurements found six resident room sinks with temperatures ranging from 133 to 140.9 degrees Fahrenheit, exceeding the facility's stated standard of not more than 120 degrees Fahrenheit. The affected rooms included rooms 200, 207, 318, 315, 431, and 426. The facility's own education materials stated that water hotter than 120 degrees Fahrenheit could cause scald burns and that staff were to stop water usage and report unsafe temperatures if water felt unusually hot or out of range. Two of the rooms with excessive temperatures were occupied by four residents who were identified as capable of entering their bathrooms and washing their hands without assistance. The Maintenance Director confirmed that temperatures had been around 130 degrees when checked and that 120 degrees was the required maximum, while the Operations Manager confirmed the temperatures of 133 to 140.9 degrees were too hot to ensure resident safety.
Incomplete discharge documentation and failure to notify the State Ombudsman
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for Resident 43, including a recapitulation of care and reconciliation of medications, after the resident was discharged from the facility to an acute care hospital. Review of the resident’s electronic medical record showed no evidence that the facility completed a comprehensive recapitulation of the resident’s stay or a medication reconciliation/discharge summary. During interview, the DON confirmed that the facility did not complete the recapitulation of Resident 43’s stay following discharge, including reconciliation of medications. The facility also failed to notify the State Ombudsman of the discharges for Resident 43 and Resident 45. Resident 43 was discharged to an acute care hospital, and Resident 45 was discharged to home. Review of Resident 45’s electronic medical record showed no evidence that the State Ombudsman was notified of the discharge. During interview, the Social Services Director confirmed that the facility did not notify the State Ombudsman of facility transfers and discharges as required for Residents 43 and 45.
Delayed Assistance With Meals
Penalty
Summary
The facility failed to provide timely eating assistance for two residents who required staff help with meals. One resident had diagnoses including Alzheimer’s dementia, malnutrition, coronary artery disease, and high blood pressure, with severely impaired cognition and partial/moderate staff assistance identified for dietary intake. During breakfast, the resident was seated in the dining room with a meal tray but was not offered setup assistance or eating support while a nursing assistant was helping others at the table. The resident made no attempt to eat or drink, was not cued or assisted when a tablemate asked if the resident was going to eat, and remained without assistance while the meal sat uncovered for 35 minutes. The resident later took one bite after being returned to the dining room, but no further assistance was provided before the resident was taken out of the dining room after consuming only one bite. A second resident with diagnoses including debility, heart failure, non-Alzheimer’s dementia, anxiety, and depression was assessed as having severely impaired cognition and requiring substantial staff assistance with eating and drinking. During breakfast, the resident remained seated at the assisted table holding a baby doll and made no attempt to eat or drink the meal. A nursing assistant briefly assisted the resident with one drink of orange juice, then walked away, and no further cueing or assistance was provided for a period of time. The resident’s biscuit was buttered later, but the nursing assistant left to assist another resident with toileting, and no other staff were available to cue or assist the resident. Total assistance with eating was not provided until 1 hour and 2 minutes after the meal was served.
Failure to Provide Adequate Nutrition Support and Feeding Assistance
Penalty
Summary
The facility failed to implement weight loss interventions for a resident with Alzheimer’s dementia, malnutrition, coronary artery disease, and hypertension. The resident’s MDS showed severely impaired cognition and partial/moderate staff assistance with dietary intake. Facility policy required nutritional assessment, monitoring of significant weight changes, notification of the physician and family, weekly weights for residents meeting weight-loss criteria, RD review, and care plan updates when weight loss occurred. The resident’s weight changed from 105 lbs. to 100 lbs. in 9 days, and later from 108 lbs. to 101 lbs. over 34 days, while meal intake remained about 50% on average. The resident also had lower-extremity fluid retention and was treated with Lasix for fluid in the legs, which affected weight fluctuations. A nutritional supplement was requested from the PCP by fax because of protein calorie malnutrition, but the facility had to send repeated faxes before the order was received 27 days later, and the supplement was not started until after the order was obtained. During breakfast observation, the resident was seated in the dining room for residents needing assistance but was not provided setup help or feeding assistance while staff attended to others. The resident made no attempt to eat or drink, was not cued effectively, and when the resident returned to the dining room later, the food had been left uncovered for 35 minutes and was not warmed. The resident consumed only one bite before being taken out of the dining room. On another day, after missing breakfast, the resident was placed in the commons area without being offered food or drink. Meal intake documentation was also missing on 13 of 26 days reviewed.
Hand Hygiene and PPE Not Used During Catheter Care
Penalty
Summary
The facility failed to perform hand hygiene at appropriate intervals and failed to use the required PPE when providing care for a resident with an indwelling urinary catheter. The resident was admitted with anemia, neurogenic bladder, non-Alzheimer's dementia, depression, a previous stroke, and high blood pressure, and required substantial to total assistance with toileting hygiene, dressing, personal hygiene, bed mobility, and transfers. The resident was also identified as having an indwelling urinary catheter and was on Enhanced Barrier Precautions. During a care observation, a nurse aide approached the resident in the commons area without a gown or gloves and transferred the resident from a recliner to a wheelchair and then to the resident's room. The nurse aide then put on a disposable gown and gloves and emptied the catheter drainage bag without first completing hand hygiene. After disposing of the urine and removing the gown and gloves, the nurse aide returned to the resident without washing hands or performing hand hygiene, used an alcohol wipe to cleanse the drainage tube of the catheter bag, adjusted the resident's clothing, and placed the foot pedals back on the wheelchair. The nurse aide then assisted the resident back to the commons area and transferred the resident into the recliner before performing hand hygiene. The nurse aide confirmed the resident was on EBP and that staff should have worn PPE for transfers, repositioning, and clothing adjustments, and should not have removed PPE while working with the resident's indwelling urinary catheter. The DON also confirmed staff had been trained to wear gloves and gowns for direct care and catheter care for the resident while on EBP.
Deficiency in Dietary Manager Qualifications
Penalty
Summary
The facility failed to employ a qualified Dietary Manager (DM), which had the potential to affect the food service provided to all residents. The deficiency was identified based on a review of the facility's job description for the DM position and the employee file of the current DM, referred to as DM-H. The job description outlined specific duties and responsibilities for the DM, including directing the dietary department, coordinating services, developing policies, and ensuring compliance with dietary requirements. It also specified educational requirements, such as training in cost control, food management, and diet therapy, and the completion of a Certified Dietary Manager (CDM) course within the first year of employment if not already qualified. Upon review, it was found that DM-H had not completed the required training or education for the DM position. This was confirmed during interviews with DM-H and the facility Administrator, both of whom acknowledged that the necessary training and classes had not been undertaken. The lack of a qualified DM had the potential to impact the quality of nutritional services provided to the residents, as the DM plays a crucial role in ensuring dietary compliance and the overall operation of the dietary department.
Deficiencies in Kitchen Sanitation and Food Temperature Maintenance
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as well as to maintain proper food temperatures, which could potentially lead to foodborne illnesses affecting all residents. Observations and audits revealed multiple cleanliness issues, including dirty floors, spills on the steam table, and crumbs on serving carts and shelves. The kitchen floor was noted to have dark, dried splatter spots with a slimy appearance, and the stove and prep areas had dried, caked-on food. Interviews with the Dietary Manager and Cook confirmed that the kitchen floors were not mopped daily as required. The facility also failed to adhere to food temperature guidelines, as documented in the October 2024 Meal Temperature Form. The dietary staff did not record food temperatures for several evening meals, and some recorded temperatures were below the recommended levels. For instance, pancakes, grilled cheese sandwiches, and various entrees were served at temperatures below 140 degrees Fahrenheit, and potato salad was served at 58 degrees Fahrenheit instead of the required 41 degrees Fahrenheit or less. Interviews with dietary staff confirmed these discrepancies. Additionally, the facility did not properly maintain the ice machine, which was last cleaned three months prior to the survey. Observations showed that the ice machine was placed on an uncleanable surface, with a floor drain partially covered and a drainage tube discolored. The filter on the machine was coated with dust and debris. The Administrator was unsure of the last cleaning date and when the next maintenance was due, indicating a lack of proper maintenance oversight.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement the required Personal Protective Equipment (PPE) during the provision of care for several residents, including Residents 12 and 235. Resident 12, who had a history of Vancomycin Resistant Enterococci (VRE), required staff to wear gloves and a gown during high-contact care activities. However, during an observation, a nurse aide assisted the resident with various tasks such as toileting and dressing without wearing the necessary PPE. Similarly, Resident 235, who was on Enhanced Barrier Precautions (EBP) due to a surgical wound, was observed receiving wound care from a Licensed Practical Nurse (LPN) who only wore gloves and not a gown, contrary to the facility's policy. The facility also failed to implement a mitigation plan to prevent potential waterborne illnesses. The Maintenance Supervisor confirmed that there was no consistent plan for flushing unused water systems to prevent water stagnation and the potential growth of pathogens like Legionella. This lack of a water management mitigation plan was acknowledged during interviews with the facility staff. Additionally, the facility did not adhere to proper hand hygiene protocols during medication administration and meal delivery. For instance, a Registered Nurse (RN) was observed handling medications for Resident 21 without performing hand hygiene or using a protective barrier on the bedside table. Similarly, a Dietary Aide (DA) failed to perform hand hygiene while delivering room trays to multiple residents. These actions were in violation of the facility's hand hygiene policy, which emphasizes the importance of hand hygiene before and after resident contact and when handling medications.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, as observed during a survey conducted from October 9 to October 16, 2024. Multiple deficiencies were noted, including stained and sagging ceiling tiles, chipped and pitted drywall, and soiled carpets with stains in various rooms. Additionally, door frames throughout the facility had chipped and missing paint, and the floors around these areas were caked with dirt and debris. The alcove outside the laundry area was heavily dusted, and the threshold of the double door entry to the 300 hallway was taped with industrial tape that was scuffed and peeling. Further observations included chipping paint on hallway walls, unsecured floor drain caps with a slimy substance beneath the ice machine, and a heavily dust-coated filter on the ice machine. A resident's fall mat had multiple tears and split seams, and a room's linoleum had a significant tear sticking up in front of a recliner. During a tour and interview with the facility Administrator, it was confirmed that these issues required repair and maintenance. It was revealed that the previous Maintenance Supervisor had been removing work orders without completing repairs, and a new Maintenance Supervisor had been employed.
Pest Control Deficiency in Resident Room and Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of tiny black bugs in the bathroom of a resident's room and dead spiders, dust, and spider webs in the facility kitchen. The facility had a pest control policy in place since 2007 and a contract with a pest control company for monthly inspections. However, during an interview, a resident reported seeing tiny black bugs in the bathroom basin, which was confirmed by observations on two separate occasions. Additionally, observations in the kitchen revealed dead spiders and unclean conditions around the windows, with a removed screen left on the window ledge. Interviews with facility staff, including a cook and the dietary manager, confirmed that the kitchen windows and screens had not been cleaned, and the presence of dead spiders and dust was evident. The pest control service summary indicated that interior rodent traps had little to no catches, suggesting a lack of effective pest control measures. The facility administrator acknowledged the issue, noting that bugs had been observed in other areas of the building as well, leading to the relocation of the affected resident to another room.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility staff failed to evaluate a resident for the ability to self-administer medications and ensure the security of medications. The facility's policy, revised in May, outlines procedures for self-administration of medications, including informing alert residents of their rights, assessing their ability, and documenting this in their medical records. However, the facility did not follow these procedures for a resident with multiple diagnoses, including cancer, coronary artery disease, and anxiety, who was moderately cognitively impaired. During observations, the resident was found with a container of Tums antacid tablets in their bathroom, which lacked a medication label and a physician's order. The resident's electronic medical record showed no evidence of an assessment for self-administration competency or a physician's order for the Tums. An LPN confirmed that the resident had not been evaluated for self-administration and did not have an order for the Tums, indicating a failure to adhere to the facility's policy and state regulations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate toileting assistance and incontinence management for a resident who required assistance with activities of daily living. The facility's policy on incontinent care, dated May 2007, required residents to be checked for incontinence every 2-3 hours. However, observations revealed that the resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was not provided with timely assistance. The resident was observed on multiple occasions with a strong odor of feces and urine, indicating a lack of proper incontinence care. On one occasion, the resident was left in a wheelchair in the corridor for over four hours without being offered toileting assistance, despite having a strong urine odor. The resident's Minimum Data Set (MDS) and care plan indicated a dependency on staff for toileting and personal hygiene. Interviews with staff confirmed that the resident had not been assisted with toileting since being dressed by the night shift, which was a minimum of four hours before assistance was finally provided. This lack of timely care was contrary to the facility's policy and the resident's care plan requirements.
Failure to Follow Fluid Restriction Orders
Penalty
Summary
The facility failed to adhere to a physician's order regarding a fluid restriction for a resident, identified as Resident 85. The facility's policy, revised in 2007, required nursing staff to notify the dietary department of fluid restriction parameters, document intake and output on the Medication Administration Record (MAR), and ensure that water pitchers were not provided at the resident's bedside. However, from October 8 to October 10, there was no documentation indicating that the facility monitored the resident's fluid intake and output to ensure compliance with the physician's order. Observations revealed that the resident had access to a full water pitcher containing 600 ml of water on two separate occasions, despite the fluid restriction. The Director of Nursing confirmed that the resident had a physician order for a 2000 ml fluid restriction and acknowledged that a full water pitcher should not have been provided in the resident's room. The Charge Nurses were responsible for documenting the resident's intake and output for each shift on the MAR to ensure compliance with the fluid restriction, but this was not done.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to monitor the dialysis access site for a resident requiring dialysis services. The facility's policy on renal dialysis care, revised in June 2009, mandates that the access site be checked for condition, bruit, and thrill every shift, and that the physician be notified of any complications. Additionally, blood pressures and venous punctures should not be performed on the extremity with the access site, and staff are responsible for preventing, identifying, and managing potential complications. The resident's admission orders indicated that they were to receive renal dialysis three times a week. However, a review of the resident's medical records, including Nursing Progress notes, Treatment Administration Record, and Medication Administration Form, revealed no evidence that the facility's nursing staff were monitoring the dialysis access site. An LPN confirmed that staff were required to assess the dialysis access site for signs of complications after treatment and to check for bruit and thrill each shift, but acknowledged that there was no evidence of these assessments being completed.
Failure to Label Insulin Pens with Open Date
Penalty
Summary
The facility failed to ensure that insulin pens were properly labeled with an open date for two residents, as required by their policy on Proper Insulin Pen Administration. During observations, it was noted that insulin pens for Residents 5 and 21 did not have an open date documented. This was confirmed during interviews with the Registered Nurse (RN) responsible for administering the insulin, who acknowledged that the pens should have been labeled with an open date. The facility's policy mandates that staff document an open date on insulin pens to ensure proper tracking and usage. However, during the survey, it was observed that the insulin pens for both residents lacked this crucial information. The Director of Nursing and the Administrator confirmed that the insulin pens should have been labeled with an open date, indicating a lapse in adherence to the facility's medication management protocols.
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What surveyors actually found near you
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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.
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Nursing homes near Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wakefield Health Care Center | 7.1 mi | ★★★★★ | 0 | 0 |
| Hillcrest Care Center | 13.1 mi | — | 0 | 0 |
| Heritage Of Emerson | 14.7 mi | ★★★★★ | 0 | 0 |
| Wisner Care Center | 18 mi | ★★★★★ | 0 | 0 |
| Colonial Manor Of Randolph | 20 mi | ★★★★★ | 13 | 0 |
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