Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Atrium Post Acute Care Of Wayne during CMS and state inspections, most recent first.
The facility failed to ensure accurate MDS assessments for several residents, leading to potential unmet care needs. A resident was discharged home, but the MDS inaccurately indicated a return was anticipated. Another resident's MDS incorrectly documented ventilator use, despite the facility not admitting residents on ventilators. Additionally, a resident's MDS inaccurately coded bowel and bladder continence, and another resident's MDS incorrectly indicated Hospice treatment. Staff interviews and facility assessments confirmed these discrepancies.
A facility failed to complete and submit a discharge MDS tracking form within 14 days for a resident with multiple diagnoses, including clostridium difficile and pressure ulcers. The MDS Coordinator and DON acknowledged the requirement, but the discharge MDS was not completed in the required timeframe, contrary to facility policy and RAI manual standards.
A resident was readmitted to the facility with multiple diagnoses, including bipolar disorder, but the PASRR Level I screen incorrectly marked the bipolar diagnosis as 'no'. This error prevented a Level II screening, which is crucial for determining necessary services. Facility staff failed to review the PASRR for accuracy, and there was confusion about responsibility for ensuring accurate screenings.
The facility failed to initiate comprehensive care plans for two residents. One resident receiving IV medication and fluids did not have these needs addressed in their care plan. Another resident, who is Muslim, had dietary restrictions and caregiver preferences that were not included in their care plan. Interviews with staff confirmed these omissions, which were contrary to the facility's care plan policy.
A facility failed to revise a resident's care plan to address a contracture of the left hand. The resident, with severe cognitive impairment and multiple diagnoses, had a physician order for a hand splint to manage the contracture. However, the care plan did not initially include this intervention. Interviews with staff revealed that the contracture should have been addressed, and the care plan was not updated until later.
A resident with a left hand contracture did not receive the prescribed restorative services, including the use of a carrot hand splint, due to miscommunication among staff about responsibility for its application. Despite a physician's order, the splint was not applied, and the care plan initially failed to address the contracture. The resident, who was severely cognitively impaired, was at risk of worsened contracture due to this oversight.
A CNA failed to follow infection control procedures while distributing lunch trays, neglecting to sanitize hands before entering and after exiting rooms with Enhanced Barrier Precautions (EBP). Despite clear signage and prior training, the CNA was unaware of EBP protocols, increasing infection risk among residents.
The facility changed its name on the sign to Alps at [NAME] without obtaining the necessary licensure and certification approval. The administrator admitted they were in the application process but had not completed the CMS-855B form. Documents provided did not include the required approval, and the administrator confirmed the absence of an approval letter from the State Licensure agency.
The facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficiency was observed for four residents with various diagnoses, including Toxic Encephalopathy, Low Back Pain, Schizoaffective Disorder, and Anxiety Disorder. Interviews with the DON and RCNS RN confirmed the orders were not signed as required.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for five residents, which could potentially lead to unmet care needs. Resident 138 was discharged home, but the MDS inaccurately indicated a return was anticipated. Interviews with the Registered Nurse and MDS Coordinator confirmed the error, as the resident was not expected to return. Resident 293's MDS inaccurately documented the use of an invasive mechanical ventilator, despite the resident not using one since admission. Observations and interviews with staff confirmed the facility did not admit residents on ventilators, highlighting a discrepancy in the MDS coding. Resident 295's MDS inaccurately coded bowel and bladder continence, despite the resident having a foley catheter and colostomy. The MDS Coordinator acknowledged the need for accurate coding in such cases. Resident 299's MDS also incorrectly documented the use of a ventilator, similar to Resident 293, despite the resident only using a tracheostomy mask with oxygen. Interviews with staff and review of facility assessments confirmed the facility's policy against admitting residents on ventilators, indicating a pattern of inaccurate MDS coding. Resident 89's MDS inaccurately indicated receipt of Hospice treatment, which was never provided. The MDS Coordinator confirmed the error, and the Director of Nursing emphasized the expectation for accurate and timely MDS coding. The facility's policy on MDS completion, which mandates adherence to the Resident Assessment Instrument (RAI) manual standards, was not followed, leading to these inaccuracies in resident assessments.
Failure to Timely Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to complete and submit a discharge Minimum Data Set (MDS) tracking form within 14 days of a resident's discharge, as required by the Centers for Medicare and Medicaid Services (CMS) system. This deficiency was identified for one resident out of 37 sampled, referred to as Resident 7. The resident was admitted with diagnoses including clostridium difficile, pressure ulcers, chronic kidney disease, and diabetes. The resident was discharged, but the discharge MDS was not completed and transmitted within the required timeframe. Interviews with the MDS Coordinator and the Director of Nursing revealed that the discharge tracking MDS should have been opened and completed within 14 days of the resident's discharge. The facility's policy, reviewed in July 2024, mandates that MDSs be filled out accurately and timely according to the RAI manual standards. However, the review of the RAI Manual dated October 2024 confirmed that a Discharge Assessment-Return Not Anticipated must be completed within 14 days after the discharge date, which was not adhered to in this case.
Inaccurate PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASRR) for a resident who was readmitted from an acute care hospital. The resident had multiple diagnoses, including schizoaffective disorder and bipolar disorder, but the PASRR Level I screen incorrectly marked the bipolar diagnosis as 'no' instead of 'yes'. This error led to the resident not qualifying for a Level II screening, which is necessary to determine if special services are needed. The facility's policy requires a Level I screen for all applicants to Medicaid-certified nursing facilities and a Level II evaluation for those who test positive at Level I. Interviews with facility staff revealed a lack of review and verification of the PASRR's accuracy. The Social Services Director and Admission Coordinator admitted to not reviewing the PASRR for accuracy, with the Admission Coordinator only uploading it into the system. The Director of Nursing confirmed the inaccuracy of the PASRR and acknowledged the importance of a Level II screening for determining necessary services. However, there was confusion about who was responsible for ensuring the accuracy of the PASRR Level I and II screenings, indicating a gap in the facility's process for handling these assessments.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were initiated for two residents, R63 and R128, out of a sample of 37. R63, who was admitted with multiple diagnoses including diabetes mellitus and acute respiratory failure, was receiving intravenous (IV) medication and fluids. However, the care plan did not include any problems or interventions related to hydration or IV medication usage. Interviews with LPN1, the MDS Coordinator, and the Director of Nursing confirmed that a care plan should have been developed to guide staff on R63's care needs, but it was not in place. R128, who was admitted with a fracture and identified as Muslim, had specific religious and cultural dietary preferences that were not addressed in the care plan. Despite having an order for no pork or chicken, the care plan did not reflect these dietary restrictions or the need for a female caregiver, as required by her religious beliefs. Interviews with R128, a CNA, the Registered Dietician, and the Dietary Manager revealed that R128 often had to request alternative foods and that her care plan did not include her cultural and religious needs. The facility's policy on the care plan process, last reviewed in September 2024, stated that care plans should incorporate identified problems with appropriate interventions to maintain the resident's highest practicable well-being. However, the care plans for R63 and R128 did not meet these requirements, as they failed to address critical aspects of their care needs, leading to deficiencies in the facility's compliance with care planning standards.
Failure to Revise Care Plan for Resident's Contracture
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident, identified as R91, was revised to address a contracture of the left hand. R91 was admitted with multiple diagnoses, including a contracture of the left hand, diabetes mellitus, Alzheimer's disease, dementia, heart failure, hypertension, and dysphagia. The resident's annual Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a functional limitation in the range of motion of the left upper extremity. Despite these conditions, the comprehensive care plan, which was initiated and revised on specific dates, did not address the contracture of the left hand. The deficiency was identified through a review of physician orders, which included a Restorative Nursing Program (RNP) order for a left carrot hand splint to manage the flexion contracture. Interviews with facility staff, including an LPN and the MDS Coordinator, revealed that the contracture should have been included in the care plan. The MDS Coordinator acknowledged that the care plan was not updated to include the contracture until a later date, and the nurse who took the RNP order should have updated the care plan accordingly.
Failure to Provide Restorative Services for Hand Contracture
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as R91, who had a contracture in the left hand. Despite having a physician's order for a Restorative Nursing Program (RNP) to use a left carrot hand splint for four hours on and four hours off daily, the splint was not applied. Observations over several days confirmed that R91 did not have the carrot hand splint on, and it was not present in the room. Interviews with staff, including the Restorative Aide, Assistant Director of Therapy, CNA, LPN, RN, and the Director of Nursing, revealed a lack of clarity and responsibility regarding the application of the splint. The Restorative Aide believed it was the nurse's responsibility, while the LPN and RN indicated that therapy was supposed to apply the splint. The Director of Nursing acknowledged that the splint should have been applied when ordered to prevent further contracture. R91 was admitted with multiple diagnoses, including contracture of the left hand, diabetes mellitus, Alzheimer's disease, dementia, heart failure, hypertension, and dysphagia. The resident was severely cognitively impaired, with a BIMS score of zero out of 15, and had a functional limitation of the range of motion on the left upper extremity. The care plan did not initially address the contracture of the left hand, and the intervention for the carrot hand splint was only added after the deficiency was noted. The facility's policy indicated that restorative nursing programs should prevent the diminution of a resident's ability to perform range of motion exercises unless clinically unavoidable, which was not adhered to in this case.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to infection control procedures during the distribution of lunch trays on one of the floors, specifically the third-floor unit. Observations revealed that a Certified Nursing Assistant (CNA2) did not sanitize his hands before entering or after exiting rooms, including those with Enhanced Barrier Precautions (EBP) signage. Despite the signage indicating the need for hand sanitization upon entry and exit, CNA2 continued to pass trays without following these protocols. During an interview, CNA2 admitted to not being aware of the EBP and mistakenly believed he had hand sanitizer in his pocket, which he did not. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that proper hand hygiene and the use of personal protective equipment (PPE) are critical in preventing the spread of infections, especially for residents on EBP. The IP and DON emphasized that failure to follow these precautions increases the risk of infection among residents, who are already vulnerable due to their health conditions. The facility's policy and signage clearly outlined the necessary precautions, yet these were not adhered to by CNA2, despite having attended a handwashing and PPE in-service training.
Facility Name Change Without Approval
Penalty
Summary
The facility failed to ensure it received licensure and certification approval before changing the name on the facility's sign. The facility was originally licensed to operate as Atrium Post Acute Care of [NAME] with 209 long-term care beds. However, observations revealed that the sign at the facility's driveway had been changed to read Alps at [NAME], with a banner completely covering the original sign. This change was made without the necessary approval, as confirmed by the facility's administrator. During an interview, the administrator admitted that they were in the application process for the name change but had not yet completed the CMS-855B form, which is part of the approval process. The administrator provided several documents, including letters from an attorney and an application for a long-term care facility license, but none of these documents included the required approval for the name change. The administrator confirmed that they did not have an approval letter from the State Licensure agency, indicating that the name change was not officially sanctioned.
Failure to Ensure Monthly Physician Orders Signed and Dated
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficiency was observed for four residents. Resident #1, with diagnoses including Toxic Encephalopathy and Malignant Neoplasm of Breast and Ovary, had unsigned orders for January, February, and March 2024. Resident #2, diagnosed with conditions such as Low Back Pain and Narcolepsy, also had unsigned orders for December 2023, January, and February 2024. Resident #3, with Schizoaffective Disorder and Type 2 Diabetes Mellitus, had unsigned orders for the same months. Resident #4, diagnosed with Anxiety Disorder and Peripheral Vascular Diseases, had unsigned orders for October, November, and December 2023, as well as March 2024. During interviews, the Director of Nursing (DON) and the Regional Clinical Nursing Services (RCNS) Registered Nurse (RN) acknowledged that the physician orders were not signed and dated as required. The DON stated that all medication orders were signed electronically and should be signed every thirty days. The RCNS RN confirmed that physicians saw their residents but did not write their notes on the same day and was unable to provide documentation of signed orders. The facility's policies, which require physician orders and progress notes to be signed and dated every thirty days, were not followed, leading to this deficiency.
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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) |
|---|---|---|---|---|
| Careone At Wayne | 1.6 mi | ★★★★★ | 8 | 0 |
| Atrium Post Acute Care Of Wayneview | 1.7 mi | ★★★★★ | 1 | 0 |
| Excel Care At Wayne | 1.9 mi | ★★★★★ | 3 | 1 |
| Preakness Healthcare Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Llanfair House Care & Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 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.