Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Careone At Wayne during CMS and state inspections, most recent first.
An LPN administered ASA 81 mg EC to a resident even though the physician’s order specified ASA 81 mg chewable once daily. The resident was alert, verbally responsive, able to swallow whole medications, and cognitively intact, but the MAR was signed as given despite the wrong ASA formulation being administered.
Failure to Apply Ordered Resting Hand Splint: A resident with hemiplegia/hemiparesis after CVA was observed without the ordered resting hand splint on the left hand on multiple occasions. The resident said staff forgot to apply it and denied refusing it, while a CNA said she usually referred the task to the nurse and an LPN said she was supposed to apply it but got busy. OT stated the resident wanted to use the splint and that staff and family had been in-serviced on how to apply it.
A resident with poor intake, weight loss, depression, anorexia, and diabetes did not receive a timely documented initial comprehensive nutritional evaluation from the RD. The chart showed only a later MNA noting malnutrition, while the RD said she had handwritten the assessment but failed to enter it into the record; the resident’s spouse was bringing food from home and staff were monitoring appetite, weight, supplements, and mood.
Physician-ordered O2 flow rates were not followed for two residents receiving respiratory care. One resident with acute and chronic respiratory failure was observed on O2 at 2.5 lpm via NC despite an order for 2 lpm every shift, and another resident with chronic respiratory failure was observed twice on O2 at 1.5 lpm via NC despite an order for 2 lpm every shift. The eMAR showed staff signing the O2 orders as ordered, and an RN/MDS Coordinator later observed the lower flow rate and adjusted it to 2 lpm.
A resident with a history of shortness of breath and congestive heart failure was observed receiving oxygen at 3 lpm via nasal cannula, despite a physician's order for 2 lpm. An LPN confirmed the discrepancy and adjusted the flow rate after it was pointed out by a surveyor. The care plan and facility policy both required adherence to the physician's order, but the higher oxygen rate was not corrected until the surveyor's intervention.
A medication administration deficiency occurred when an LPN failed to ensure a resident took their prescribed medication, leaving it at the bedside. The resident, who was cognitively intact, had a physician's order for docusate sodium, which was signed off as administered. However, the nurse did not observe the resident taking the medication, resulting in it being left unattended. This incident reflects a lapse in the facility's adherence to medication administration protocols.
A facility failed to maintain necessary respiratory care for a resident receiving nebulizer treatments. The resident's nebulizer mask was not dated, and there was no care plan for the treatment. Interviews revealed that facility policies for labeling, cleaning, and storing respiratory equipment were not followed, and the equipment was found with medication sediment. The resident had diagnoses of CHF and pneumonia, and a BIMS score indicating intact cognition.
A facility was found deficient in infection control practices, with an LPN improperly disposing of PPE and a CNA failing to perform hand hygiene during meal service. The LPN did not dispose of PPE inside EBP rooms and placed gloved hands in scrub pockets, while the CNA did not clean hands between resident interactions, including those on EBPs. Facility policies lacked clear guidance on these practices.
Medication Administered Contrary to Physician Order
Penalty
Summary
The facility failed to follow a physician’s order for one resident during medication administration. On 12/18/2025 at 8:24 AM, an LPN administered Aspirin (ASA) 81 mg enteric coated (EC) to a resident who was alert, verbally responsive, and able to swallow medications whole. The resident’s record showed diagnoses including multiple sclerosis, and a Brief Interview/Assessment for Mental Status completed on 12/17/2025 showed a score of 15 out of 15, indicating the resident was cognitively intact. Review of the physician’s orders and the December 2025 MAR showed an order for ASA 81 mg chewable tablet by mouth once daily at 8 AM. The MAR was signed as administered by the LPN, but the medication actually given was ASA 81 mg EC rather than the ordered chewable form. The LPN acknowledged that ASA 81 mg EC should not have been administered when the order specified ASA 81 mg chewable.
Failure to Apply Ordered Resting Hand Splint
Penalty
Summary
The facility failed to follow a physician’s order for a resting hand splint to the left hand of one resident with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident’s admission MDS showed a BIMS score of 14 out of 15, indicating intact cognition, and the care plan included use of the resting hand splint on the left hand while in bed, removed for hygiene and skin checks. The order summary reflected that the splint was to be applied every shift and worn when in bed, with the order active since 11/24/25. During observation, the resident was seen without the resting hand splint on the left hand on two separate occasions. The resident stated they did not know where the splint was, said staff must have forgotten to put it on, and denied refusing it. Later, the resident again was observed not wearing the splint and stated they were waiting for a family member to help put it on, adding that staff usually put it on but probably forgot. The CNA stated she sometimes puts the splint on but usually refers to the nurse, and the LPN stated she was supposed to put it on but got busy. OT stated the resident wanted to use the splint and that OT had provided in-service training to family, aides, and nurses on how to apply it.
Late Documented Nutritional Evaluation
Penalty
Summary
The registered dietitian failed to provide a timely initial comprehensive nutritional evaluation for one resident who had recently been admitted with diagnoses including type 2 diabetes mellitus with hypoglycemia, anorexia, anxiety, depression, and urinary tract infection. On observation, the resident was asleep in bed with a nutritional supplement and water at the bedside, and the unit LPN stated the resident ate poorly at times, had lost weight since admission, was receiving appetite-stimulating medication, and was depressed. The resident’s spouse was observed assisting with lunch and was bringing food from home daily. Record review showed that the RD had placed a comprehensive nutritional care plan on admission, but there was no documented comprehensive nutritional evaluation in the medical record at that time. One week after admission, the RD documented a Mini Nutritional Assessment that noted decreased food intake, weight loss, mobility needs, psychological problems, height and weight, and a score of 7 indicating malnutrition, but it did not include calculations for nutritional needs or a documented diet type. The RD stated she had handwritten the comprehensive evaluation in a notebook but failed to document it in the medical record, and the LNHA and DON acknowledged the evaluation was late.
Physician-Ordered Oxygen Flow Rates Not Followed
Penalty
Summary
The facility failed to ensure that physician orders for oxygen were followed for 2 residents reviewed for respiratory care. Resident #18 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, had a BIMS score of 15/15, and had an active order for oxygen at 2 lpm via nasal cannula every shift for shortness of breath. The resident was observed sitting in bed with oxygen at 2.5 lpm via nasal cannula attached to the oxygen concentrator, while the care plan directed staff to administer oxygen per physician order. The eMAR showed nurses signing the oxygen order as ordered, despite the observed flow rate being different from the physician order. Resident #29 was admitted with diagnoses including chronic respiratory failure and had a BIMS score of 9/15. The resident had an active order for oxygen at 2 lpm via nasal cannula every shift for shortness of breath, and the care plan also directed staff to administer oxygen per physician order. However, the resident was observed in bed asleep with oxygen at 1.5 lpm via nasal cannula attached to the concentrator on two separate observations. During interview, the LPN stated the oxygen was at 2 lpm, while the RN/MDS Coordinator observed it at 1.5 lpm and then adjusted it to 2 lpm. The eMAR showed nurses signing the oxygen order at 2 lpm every shift.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency was identified when a resident with diagnoses including shortness of breath and congestive heart failure was observed receiving oxygen therapy at a rate of 3 liters per minute (lpm) via nasal cannula, despite an active physician order specifying oxygen at 2 lpm continuously. The surveyor observed the resident on two separate occasions receiving oxygen at 3 lpm, and upon inquiry, an LPN confirmed the order was for 2 lpm and adjusted the flow rate accordingly. The resident's care plan also indicated that oxygen should be administered per physician order. A review of the resident's medical record confirmed the physician's order for 2 lpm oxygen via nasal cannula, and the facility's policy on oxygen administration stated to follow the ordered rate. The discrepancy between the ordered and administered oxygen flow rate was not identified or corrected until brought to the attention of staff by the surveyor. No additional information or clarification was provided by facility leadership during the surveyor's interview.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by not ensuring that a medication was administered to a resident and not left at the bedside. During a medication administration observation, an LPN was seen retrieving a medication capsule from a resident's bedside, which the resident had not taken. The LPN admitted to not being aware of the medication being left at the bedside and acknowledged that medications should not be left with residents. The Director of Nursing confirmed that medications should not be left at the bedside, indicating a lapse in following the facility's medication administration policy. The resident involved, identified as cognitively intact, had a physician's order for docusate sodium to be administered in the evening. The medication administration record indicated that the medication was signed off as given the previous evening. However, a follow-up investigation revealed that the nurse responsible for administering the medication did not observe the resident taking it, leading to the medication being left at the bedside. This incident highlights a failure in the facility's process to ensure medications are properly administered and not left unattended with residents.
Failure to Maintain Respiratory Care Standards
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident receiving nebulizer treatments according to standards of practice. The deficiency was identified when a surveyor observed that the nebulizer treatment mask for a resident was not dated, and the resident was unaware if it had been changed weekly. The resident, who had diagnoses including congestive heart failure and pneumonia, had a BIMS score indicating intact cognition. The resident's medical records showed an order for nebulizer treatment every six hours for shortness of breath, but there was no care plan in place for the nebulizer treatment or any respiratory care plans. Interviews with the Infection Preventionist and the Director of Nursing revealed that the facility's policy required respiratory equipment to be labeled, dated, washed between uses, and stored in a dated patient care bag. However, the surveyor and the Infection Preventionist observed the equipment was not labeled and had medication sediment in the chamber. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged the absence of a respiratory treatment care plan for the resident. The facility's policy for administering medication through a nebulizer outlined specific steps for cleaning and storing the equipment, which were not followed in this case.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection control practices concerning the use and disposal of personal protective equipment (PPE) and hand hygiene. During a medication administration observation, a Licensed Practical Nurse (LPN) was seen entering and exiting rooms with Enhanced Barrier Precautions (EBP) without properly disposing of PPE inside the room. The LPN was observed placing gloved hands into her scrub pockets, which is against protocol, and disposing of used PPE in a medication cart garbage bin outside the resident's room. The LPN acknowledged the improper disposal of PPE and the inappropriate handling of gloved hands. Additionally, during a meal service observation in the South Unit, a Certified Nursing Assistant (CNA) failed to perform hand hygiene between resident interactions. The CNA was observed delivering food trays and assisting residents without cleaning hands before entering or after exiting rooms, including those with EBP signage. The CNA admitted to not being aware of the requirement for hand hygiene when dealing with residents on EBPs. The facility's policies on Enhanced Barrier Precautions and hand hygiene were reviewed, revealing gaps in the guidance on PPE disposal and hand hygiene practices. The Infection Preventionist and the Director of Nursing acknowledged the lapses in protocol adherence, but no further information or corrective actions were provided at the time of the survey.
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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) |
|---|---|---|---|---|
| Atrium Post Acute Care Of Wayneview | 0.6 mi | ★★★★★ | 1 | 0 |
| Llanfair House Care & Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Atrium Post Acute Care Of Wayne | 1.6 mi | ★★★★★ | 0 | 0 |
| Complete Care At Wayne Hills Rehab & Resp Center | 2.5 mi | ★★★★★ | 18 | 0 |
| Arbor Ridge Rehabilitation And Healthcare 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.