Below 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 Excel Care At Wayne during CMS and state inspections, most recent first.
A facility failed to keep complete and readily accessible records for a resident with CHF, UTI, and polyosteoarthritis. The resident had a right shin hematoma, but nursing notes did not document the injury or notification to the EC/representative, and the investigation record lacked the name, date, and time of notification. CNA task records for bladder, bowel, and toileting hygiene also contained multiple blank and unsigned entries.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after exiting through an unsecured back door in a construction area where the wander guard system was not functioning. The required daily alarm checks were not completed, and staff were unaware of all residents at risk for elopement due to inconsistent updates to the Neighborhood Watch list. Another resident at risk for elopement was not recognized by some staff as a wanderer or as wearing a wander guard, highlighting failures in communication and supervision.
A resident with severe cognitive impairment and a history of wandering eloped from the facility and was found outside by staff after being reported missing. Although the resident was assessed and returned safely, nursing staff failed to document the elopement event in the medical record, contrary to professional standards and facility policy. Leadership confirmed that such incidents should be recorded to ensure continuity of care.
The facility failed to protect hazardous areas as per NFPA 101:2012 standards. Observations revealed that the kitchen door did not close properly, the storage room by laundry lacked a self-closing device, and the dietary storage room door did not latch. Additionally, the basement medical records room stored combustible materials without a self-closing door.
The facility failed to conduct monthly inspections of the range-hood fire suppression system's wet chemical cylinder, as required by NFPA standards. An observation revealed that while a semi-annual inspection was completed, documentation for monthly inspections from June to November 2024 was missing. This deficiency, confirmed during an interview, had the potential to affect all residents.
The facility failed to maintain its fire system sprinkler heads and ceiling smoke barriers according to NFPA standards. Observations revealed missing escutcheon plates and gaps in ceiling tiles near sprinkler heads in various areas, including the kitchen office, bathrooms, and dining room. These deficiencies were confirmed through interviews and communicated during the Life Safety Code survey exit conference.
The facility did not provide an instructional placard near the Class K fire extinguisher in the kitchen, as required by NFPA standards. This placard should have indicated that the fire protection system must be actuated before using the extinguisher. The deficiency was confirmed through staff interviews and discussed during the Life Safety Code exit conference.
The facility's generator lacked a remote manual stop station, as required by NFPA standards, potentially affecting all residents. Staff were aware of the requirement but could not locate the stop station during the survey.
The facility failed to establish policies and procedures for the maintenance and testing of Patient Care Related Electrical Equipment (PCREE) and did not maintain documentation of testing, inspection, and repairs as required by NFPA 99. During a survey, it was found that there were no comprehensive maintenance programs or inspection reports available, and the facility representatives were informed of this deficiency.
The facility failed to provide a "NO Exit" sign at a stairway door near room 118, which was neither an exit nor a way of exit access. The door was marked with a sign indicating stairs and had an exit sign nearby, making it likely to be mistaken for an exit. This arrangement could affect all first-floor residents, as the stairwell serves as an exit from the second floor to the first floor but not from the first floor.
The facility failed to maintain operational bathroom exhaust fans as required by NFPA standards. During a tour, it was found that 3 out of 7 resident room bathrooms lacked windows and had non-operational exhaust fans, affecting rooms 122, 126, and 218. The main exhaust fan for the section was down, impacting all bathrooms served by that unit, potentially affecting 50 residents.
The facility failed to ensure call bells were within reach for two residents, one with moderately impaired cognition and another with severe cognitive impairment. Both residents had care plans that included using the call bell for assistance, but observations showed the call bells were consistently out of reach, contrary to facility policy.
A facility failed to use a blood pressure monitor correctly, leading to repeated error readings for a resident. Additionally, an antibiotic treatment was not administered as ordered for another resident with a stage 4 pressure ulcer. The facility's policy did not require notifying the physician unless two consecutive doses were missed, but the Director of Nursing acknowledged that the physician should have been informed of the missed doses.
A resident with severe cognitive impairment and frequent urinary incontinence was found with two saturated incontinence briefs, contrary to facility policy. The CNA responsible had not provided care that morning due to a heavy workload, and the resident's care plan lacked incontinence care instructions.
The facility had a medication administration error rate of 7.6%, exceeding the acceptable 5% threshold. Errors included an LPN administering the wrong dosage of Sennoside to a resident and another LPN failing to take a resident's blood pressure immediately before administering Amlodipine, as required by the physician's order. These issues were identified during a survey and discussed with facility leadership.
Incomplete Documentation of Resident Injury and Care Records
Penalty
Summary
The facility failed to maintain accurately documented, complete, and readily accessible medical records for one resident. Resident #125 had diagnoses including urinary tract infection, acute on chronic congestive heart failure, and polyosteoarthritis. The resident’s MDS dated 12/1/25 indicated a BIMS score of 15/15, showing cognitive intactness, and also showed dependence for toileting hygiene, substantial to maximum assistance with personal hygiene and transferring, and frequent bladder incontinence. A physician progress note dated 1/9/26 documented that the resident had a right shin hematoma that the resident was unaware of having sustained, with the area described as tender but improving. The note also stated the resident was instructed to elevate the leg, apply ice, and avoid physical contact to the site, and that the physician discussed the condition with the resident’s relation at the bedside. However, review of January 2026 nursing progress notes found no nursing documentation about the hematoma and no documentation of notification to the PMD or emergency contact regarding the injury. The facility’s investigation dated 1/6/26 stated that during rounds the former DON was notified the resident was found with a right shin hematoma, but the document did not include the name of the emergency contact or representative, the date, or the time of notification. The DON confirmed the investigation was not part of the medical record and acknowledged there was no name, date, or time documented for the notification. In addition, the December 2025 and January 2026 CNA task documentation reports for bladder elimination, bowel elimination, and toileting hygiene contained multiple blank and unsigned entries.
Failure to Prevent Elopement Due to Inadequate Supervision and System Malfunction
Penalty
Summary
The facility failed to provide adequate supervision to a severely cognitively impaired resident with a known history of wandering and elopement risk, resulting in the resident eloping from the facility. The resident, who had dementia, epilepsy, a history of falls, and a BIMS score indicating severe cognitive impairment, was last seen by staff near the nurse's station and was later found outside the facility by members of the public. The resident was wearing a wander guard, but exited through an unsecured back door in a construction area where the wander guard system was not operational due to a malfunctioning pin pad and disconnected power to the magnet lock. The required daily check of the door alarms had not been completed by the Manager on Duty prior to the incident. Staff interviews and facility records revealed that the resident had been identified as an elopement risk days prior, with a care plan and wander guard in place. However, the resident was able to leave the building through a series of unsecured and unsupervised areas, including a construction zone with an unzipped dust barrier and unlocked doors, ultimately reaching a sidewalk adjacent to a highway. The wander guard system did not alert staff to the resident's exit, and the malfunction was only discovered after the elopement occurred. The facility's elopement and wander guard policies required regular maintenance and testing of the system, as well as supervision in the event of equipment malfunction, but these procedures were not followed. Additionally, the facility failed to ensure that all staff were aware of which residents were at risk for elopement. A second resident, also with severe cognitive impairment and a history of wandering, was not recognized by some staff as a wanderer or as wearing a wander guard. The Neighborhood Watch list, which identified residents at risk for elopement, was not consistently updated or communicated to all staff, leading to confusion and lack of awareness about residents requiring increased supervision. This lack of communication and oversight contributed to the deficient practice in preventing elopement.
Removal Plan
- Resident #2 was located and brought back in building, wanderguard was functional, the resident was assessed with no injuries and placed on 1:1 supervision.
- The Director of Maintenance checked doors, elevators, and wanderguard systems to confirm functional, and identified a possible exit in a non-residential area and secured with alarm.
- The facility began an investigation, and wanderguard devices were tested.
- The Neighborhood Watch list with residents' photos was updated.
- An elopement drill was conducted.
- Certified Nursing Aide (CNA) assignments were updated to include identification of residents at risk for elopement.
- All staff were educated on elopement process.
Failure to Document Resident Elopement in Medical Record
Penalty
Summary
The facility failed to ensure that nursing staff documented a resident's elopement from the facility in the resident's medical record, as required by professional standards of practice. On the date of the incident, a resident with severe cognitive impairment and a history of dementia, epilepsy, and falls was last seen at the nurse's station before being discovered missing from their room. An elopement protocol was initiated, and the resident was found outside the facility by staff after being seen by visitors. The resident was returned to the facility, assessed for injuries, and placed on one-to-one supervision. A review of the resident's medical record revealed that there was no documentation of the elopement incident in the progress notes. The only note present was a nurse's progress note that did not mention the elopement, but instead documented a skin assessment and foot evaluation. Interviews with nursing staff confirmed that the elopement should have been documented in the resident's medical record, and that such incidents are typically charted post-incident to ensure all staff are aware of the event. The facility's own policy on nursing documentation requires that all changes in condition or behavior, as well as nursing interventions and observations, be documented accurately and promptly. The Director of Nursing and other leadership confirmed during interviews that elopement is considered a behavior that should be documented in the medical record. The lack of documentation for this incident was identified as a failure to follow both professional standards and facility policy.
Deficiencies in Hazardous Area Protection
Penalty
Summary
The facility failed to ensure that hazardous areas were adequately protected in accordance with NFPA 101:2012 Edition, Sections 19.3.2.1, 7.2.1.8, 9.7, and 8.4. During observations, it was noted that the kitchen door, which was on a hold-open device, did not close completely into its frame when released, even after multiple tests. Additionally, the storage room by the laundry had combustible boxes stored without a self-closing or automatic closing device on the door. Similarly, the dietary disposable storage room door failed to positively latch when opened to 90 degrees and released, despite repeated testing. Further observations revealed that the basement medical records room contained combustible paper records with boxes stacked throughout, and the door to this room also lacked a self-closing or automatic closing device. These deficiencies were confirmed through interviews conducted at the time of the observations. The issues were communicated to the relevant personnel during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: A self-closer was added to kitchen door and laundry storage room on 12/14/24. A latch was added to dietary disposable storage room and medical records room on 12/14/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: Maintenance has been serviced on protecting hazardous areas enclosures. The Maintenance Director/designee will conduct monthly walking audits of all doors within hazardous areas for compliance and tracking. Findings of audits will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review audits on a quarterly basis for 12 months to ensure compliance.
Failure to Perform Monthly Inspections of Fire Suppression System
Penalty
Summary
The facility failed to perform monthly inspections of the range-hood fire suppression system's wet chemical cylinder as required by NFPA 17 A: 2009 Edition and NFPA 96: 2011 Edition. During an observation, it was noted that the semi-annual inspection was conducted on December 2, 2024, and the inspection tag was new. However, the facility lacked documentation for the monthly inspections for the previous six months, specifically for June through November 2024. This oversight was confirmed during an interview with a staff member at the time of the observation. The deficiency was identified during a survey conducted on December 12, 2024, and was discussed with facility representatives at the Life Safety Code exit conference on December 13, 2024. The absence of monthly inspection documentation for the range-hood fire suppression system had the potential to affect all residents, as it is a critical component of the facility's fire safety measures. No further documentation was provided to demonstrate compliance with the required monthly inspections.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The Maintenance director reached the vendor which confirmed that the inspection was completed, however they do not keep previous tags. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in serviced to conduct monthly audits of kitchen hood suppression inspections and automatic sprinkler separations. Maintenance/designee will complete audit inspections and sign off tags of suppression systems the first week of every month. Monthly audit logs will be submitted to the Administrator for review and kept in the Maintenance office. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.
Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its fire system sprinkler heads and ceiling smoke barriers in accordance with NFPA 101: 2012 edition and NFPA 25: 2011 edition. During a tour of the facility, several deficiencies were observed, including a missing escutcheon plate on the kitchen office sprinkler head and missing drop ceiling components in the bathrooms of rooms 122 and 126, which caused gaps near the sprinkler heads. Additionally, the storage closet by room 212 had a space along the side of the sprinkler escutcheon cap penetrating through the drop ceiling, and the second-floor dining room had two sprinkler heads missing escutcheon plates. These observations were confirmed through interviews conducted at the time of the survey. The deficiencies were communicated to the relevant staff during the Life Safety Code survey exit conference. The report highlights the potential impact of these deficiencies on all residents, as the facility did not ensure the proper maintenance of its fire protection systems.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The Maintenance Director received a proposal from the vendor for kitchen office sprinkler head (X1) and second floor dining room (X2) for escutcheons. See attached evidence. The drop ceiling was replaced in the bathroom of rooms 122 and 126 on 12/14/24. The drop ceiling was replaced in the storage closet by room 212 on 12/14/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the Sprinkler Systems. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in-serviced on Sprinkler System Maintenance and Testing. The Maintenance director/designee will conduct monthly walking audits of all sprinkler systems on all floors. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.
Missing Instructional Placard for Fire Extinguisher
Penalty
Summary
The facility failed to comply with NFPA standards by not providing an instructional placard near the Class K portable fire extinguisher in the kitchen. This placard should have indicated that the fire protection system must be actuated before using the extinguisher. This deficiency was observed during an inspection at 11:26 AM, and the absence of the placard was confirmed through interviews with staff present at the time. The issue was discussed with the relevant personnel during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The K rated fire extinguisher was moved to the proper location next to instruction placard. It is still in the kitchen in an accessible location. See attached evidence. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in-serviced on keeping all monthly placards of portable fire extinguishers. The maintenance Director/designee will maintain a log on all placards monthly. Findings will be submitted to the Administrator for review. Additionally, the maintenance Director will keep onsite placards for a period of at least one year prior to the current year. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audits on a Quarterly basis x 12 months to ensure compliance.
Lack of Remote Manual Stop Station for Generator
Penalty
Summary
The facility failed to ensure the Essential Electrical System (EES) was equipped with a remote manual stop station for the generator set, as required by NFPA 99: 2012 Edition and NFPA 110: 2010 Edition. During an observation on December 12, 2024, it was noted that the facility's generator, located outside the building, lacked a remote manual stop station. This deficiency was identified as having the potential to affect all residents. In an interview conducted on December 13, 2024, a staff member acknowledged awareness of the requirement for a remote manual stop station but was unable to locate one at the time. The absence of this critical safety feature was confirmed during the Life Safety Code Exit conference, highlighting a significant oversight in the facility's compliance with safety regulations.
Plan Of Correction
1/21/25 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: Powerhouse Generators will be installing the remote manual stop on 1/21/25, due to the recent cold weather and freezing of the ground. Appointment confirmation attached. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated to maintain remote manual stop and electrical systems. The Maintenance Director/Designee will test remote manual stop during weekly generator testing. Findings will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audits on a Quarterly basis x 12 months to ensure compliance.
Deficiency in Electrical Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to provide policies and procedures for Patient Care Related Electrical Equipment (PCREE) and did not conduct maintenance of electrical equipment or maintain a record log of all required testing, test results, and repairs in accordance with NFPA 99: 2012 Edition. This deficiency was identified during a documentation review conducted over three days, where it was revealed that there was no documentation of PCREE testing, inspection, and maintenance available. The surveyor requested the Maintenance Coordinator and Administrator to provide any PCREE documents, but none were provided. In an interview, it was stated that the facility's electrical equipment is inspected and labeled with a sticker, but there were no comprehensive policies or procedures for maintenance, testing, and inspection of PCREE. Additionally, there were no inspection reports available for the facility's patient care-related electrical equipment. This lack of documentation and established procedures was communicated to the facility representatives during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The VPPO on 12/24/24 updated Electrical Equipment Testing and Maintenance policy and procedure dated 5/1/24, to include Patient Care Related Electrical Equipment (PCREE). 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated on the policy for the maintenance of electrical equipment, and to tag and log all required testing and results and repairs. The Maintenance Director/designee will conduct routine monthly audits of all electrical equipment per manufacturer specifications for results and repairs. Maintenance will tag all inspected equipment. Findings will be submitted to the Administrator for review. 4. Monitoring corrective action: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.
Inadequate Exit Signage at Stairway Door
Penalty
Summary
The facility failed to provide appropriate signage at a stairway door, which was neither an exit nor a way of exit access, as required by NFPA 101: 2012 Edition, Section 19.2.10 and 7.10.8.3.1. During an observation, it was noted that the stairwell door by room 118 was marked with a sign indicating stairs and had an exit sign suspended from the corridor ceiling nearby. The exit sign, positioned approximately 8 inches to the left of the door's opening edge and 7 inches off the corridor wall, featured chevron arrows pointing in both directions. This arrangement made the door likely to be mistaken for an exit, necessitating a "NO Exit" sign on the door. The stairwell serves as an exit from the second floor to the first floor but is not an exit from the first floor, potentially affecting all first-floor residents.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: No Exit sign was placed on stairwell door by room 118 on 12/23/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All 1st floor residents had the potential to be affected. 3. Systemic changes to ensure that deficient practice does not recur: Maintenance has been in service on Exit signage. Maintenance/designee will conduct monthly walking audits of all exit doors outside for compliance and tracking. Findings of audits will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the audit on a Quarterly basis x 12 months to ensure compliance.
Non-Operational Bathroom Exhaust Fans
Penalty
Summary
The facility failed to maintain operational bathroom exhaust fans in accordance with NFPA 101:2012 edition, Sections 19.5.2.1, 9.2, and NFPA 90A. During a facility tour, it was observed that 3 out of 7 resident room bathrooms did not have windows, and the exhaust fans were non-operational. These rooms were identified as 122, 126, and 218. An interview confirmed that the main exhaust fan for the section was down, affecting all bathrooms served by that unit. This deficiency had the potential to affect 50 residents.
Plan Of Correction
1/13/25 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The maintenance Director has repaired exhaust fans in rooms 122, 126 and 218. See evidence attached. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated in maintaining heating, ventilation, and air conditioning in all patient rooms. The Maintenance Director/ designee will audit HVAC systems throughout the facility, in patient rooms every six months. Findings will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the bi-yearly audit on a Quarterly basis x 1 year to ensure compliance.
Failure to Ensure Call Bells Within Reach of Residents
Penalty
Summary
The facility failed to maintain the call bell within reach of residents, which was identified for two residents. Resident #8, who has moderately impaired cognition and requires maximum assistance for Activities of Daily Living (ADL) care, was observed multiple times seated in a wheelchair with the call bell affixed to the right enabler, out of reach. Despite the care plan intervention to encourage the resident to use the bell for assistance, the call bell was consistently placed out of reach by the Certified Nursing Assistants (CNAs) responsible for the resident's care. Resident #11, who has severe cognitive impairment and is dependent on staff for ADL care, was found in bed with the call bell on the floor under the bed, making it inaccessible. The resident's care plan also included an intervention to encourage the use of the call bell for assistance. The facility's policy requires that residents have a means to call staff for assistance, but this was not adhered to, as confirmed by the CNAs and the Licensed Nursing Home Administrator.
Plan Of Correction
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 21 residents reviewed for the accommodation of needs (Resident #8 and #11). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #11 call bell was placed within reach immediately. The unit managers ensured the call light was within reach daily. Plan of care reviewed. "Resident #8 call bell was placed within reach immediately. Plan of care reviewed. "Education was conducted with assigned CNAs by Director of Nursing regarding the placement of call bell after care. "Education was completed with all nursing staff regarding the placement of the call bell. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by this deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Ongoing education will be provided to all nursing staff by the Director of Nursing regarding the placement of call bells after care. "Call bell policy reviewed, and education provided to all nursing staff by Director of Nursing. "The Director of Nursing or designee will check the placement of call bells daily at the beginning of each shift. 4. Monitoring corrective actions: "The Director of Nursing or designee will audit 5 call bells placement weekly x 3 months and then monthly x 3 months. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
Deficiencies in Blood Pressure Monitoring and Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a blood pressure apparatus was used in accordance with the manufacturer's specifications. During an observation, a Licensed Practical Nurse (LPN) attempted to take a resident's blood pressure multiple times using incorrect techniques, such as placing the cuff on the forearm instead of the upper arm and positioning the rubber tube on the outside of the arm. These errors resulted in repeated error readings. The Registered Nurse/Unit Manager (RN/UM) later confirmed the incorrect technique and stated that the LPN would be educated on the proper use of the device. Additionally, the facility did not administer an antibiotic treatment as ordered by the physician for a resident with a stage 4 pressure ulcer. The resident reported that there were days when the prescribed Gentamicin was not administered. A review of the electronic Medication Administration Record (eMAR) confirmed that doses on two separate days were missed. The facility's policy did not require notifying the physician unless two consecutive doses were missed, but the Director of Nursing acknowledged that the physician should have been informed of the missed doses. The report highlights deficiencies in both the administration of medication and the use of medical equipment, which were not in accordance with professional standards of practice. The facility's failure to adhere to these standards resulted in improper care for the residents involved, as evidenced by the incorrect blood pressure readings and the missed antibiotic doses.
Plan Of Correction
Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) blood pressure apparatus was utilized in accordance with the manufacturer's specifications, b.) an antibiotic treatment was administered as ordered by the physician, and in accordance with professional standards of practice. This deficient practice was observed during the medication pass observation of 1 of 5 nurses who administered to 1 of 6 residents (Resident #20) and identified for 1 of 1 resident investigated for abuse (Resident #16). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #20 [R] was taken using the correct method as per manufactures specification. Resident #20 was not affected by the deficient practice. 'US FOIA (b)(6) was educated immediately about proper use of NJ Ex apparatus by unit manager. "Resident #16 was not affected by deficient practice. MD was notified of missed treatments. No new orders were given. "Education was completed by the Director of Nursing with US FOIA (b)(6) regarding the process to be followed when medications are not available. "Medication administration policy was reviewed and updated to reflect communication of missed medication with the physician. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education was provided by the Director of Nursing to all nursing staff regarding proper placement of blood pressure cuff. "Education was provided by the Director of Nursing to all nursing staff regarding the process to be followed when medications are not available and documenting communication with physician. "Blood Pressure cuff placement competency added to orientation and annual training. 4. Monitoring of corrective actions: "The Director of Nursing or designee will audit the placement of blood pressure cuff by 2 nurses weekly for 1 month and then monthly for 6 months. "The Director of Nursing or designee will audit 5 residents with treatment orders weekly for 1 month and then monthly for 6 months. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
Inadequate Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, identified as Resident #71, who was dependent on staff for assistance. During an observation, the surveyor found the resident seated in a wheelchair in the bathroom with two saturated incontinence briefs, which is against the facility's policy. The Hospitality Aide present was not assigned to provide direct care and had to summon the Certified Nursing Assistant (CNA) responsible for the resident. Upon arrival, the CNA confirmed the inappropriate use of double diapers and admitted to not having provided care to the resident that morning due to having 12 residents on her assignment. Resident #71 was admitted with chronic kidney disease, a fracture of the right femur, and hypertension, and had a severe cognitive impairment with a BIMS score of 7 out of 15. The resident required supervision with toileting and was frequently incontinent of urine. However, the resident's care plan did not address incontinence care, which was a requirement according to the facility's policy. The Director of Nursing acknowledged the oversight and confirmed that the care plan for incontinence care was not initiated until after the surveyor's inquiry.
Plan Of Correction
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that NJ Ex Order 26.4b1 was provided to a NJ Ex Order 26.4b1 resident for 1 of 4 residents reviewed for J Exec Order 26.461 care (Resident #71) on 1 of 2 nursing units, X-floor unit. 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #71 was assisted with NJ Ex Order 26.4(b)(1) NJ Ex Ord care immediately. was assessed, no changes in NJ Ex Order 26.4(b)(1) noted. "Education was provided by the Director of Nursing to U.S. FOIA (b) (6) regarding timely NU Ex Order 26.4(b)(1) care. "Plan of care updated for all residents who prefer to use. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All incontinent and dependent residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education provided by Director of Nursing to all nursing staff regarding timely incontinent care as per residents needs. "Residents requesting for two briefs will be evaluated quarterly and annually and preference will be included in the plan of care. "Incontinence rounds added/included in the unit managers daily rounding to ensure incontinence care is provided as per the residents needs. 4. Monitoring of corrective actions: "The Director of Nursing or designee will audit 5 incontinent residents weekly for month and then monthly for 6 months to ensure incontinent care is provided in a timely manner. "The Director of Nursing will audit all incontinent residents for preference of two briefs weekly for 1 months and then monthly for 6 months to ensure residents preference is reflected in the plan of care. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 7.6%, which exceeds the acceptable threshold of 5%. During a medication pass observation, two errors were identified involving two residents. The first error occurred when an LPN prepared medication for a resident with a physician's order for Sennosides - Docusate sodium 8.6 mg - 50 mg. Instead, the LPN poured Sennoside 8.6 mg from a house stock bottle, which was incorrect according to the physician's order. This error was acknowledged by the LPN upon review with the surveyor. The second error involved another LPN who prepared medication for a resident with a physician's order for Amlodipine 10 mg, which required holding the medication if the systolic blood pressure was less than 110. The LPN recorded the resident's blood pressure from a notebook into the electronic Medication Administration Record (eMAR) but admitted to taking the blood pressure earlier in the morning rather than immediately before administering the medication, as required by the physician's order. These deficiencies were discussed with the Director of Nursing and other facility leaders during the survey.
Plan Of Correction
Based on observation, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication pass on 12/4/24, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 26 opportunities, and two (2) errors observed which calculated to a medication administration error rate of 7.6%. The deficient practice was identified for 2 of 5 nurses for 2 of 6 residents, (Resident #97 and #20). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "LPN #1 was educated by the Director of Nursing about verification of correct medication during medication administration and process to follow if a medication is not available. A medication administration observation was completed on LPN #1 by the Director of Nursing. Resident #97 did not receive the wrong medication and was [R] by the deficient practice. LPN #2 was educated by the Director of Nursing about proper medication administration procedure when administering NJ Ex Order 26.4(b)(1) medication with a NJ Ex Order 26.4(b)(1). LPN #2 was educated to complete blood pressure right before administering medication. The LPN #2 completed NJ Exec Order 26.4b1 right after and administered medication as per protocol. Resident #20 was not affected by the deficient practice. A medication administration observation was completed on LPN #2 by the Director of Nursing. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education completed, and the medication administration policy and procedure revised and updated on 12/20/24, with all nurses. The pharmacy consultant will continue with medication administration observations and education monthly to ensure competency of all nurses. 4. Monitoring of corrective actions: "The Director of Nursing or designee will complete medication observation on 3 nurses monthly for 6 months to ensure competency of nurses with an emphasis on medication verification and blood pressure completion right before administering hypertensive medications with BP parameter. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
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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) |
|---|---|---|---|---|
| Preakness Healthcare Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Atrium Post Acute Care Of Wayne | 1.9 mi | ★★★★★ | 0 | 0 |
| Windmere | 1.9 mi | ★★★★★ | 7 | 0 |
| Doctors Subacute Healthcare, Llc | 2.7 mi | ★★★★★ | 6 | 0 |
| Christian Health Care Center | 3.1 mi | ★★★★★ | 13 | 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.