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 Llanfair House Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of diabetes and vascular disease developed a pressure ulcer that was not reported or managed according to facility policy. Initial treatment with Zinc Oxide cream was ordered, but documentation was inconsistent, and the condition worsened. The resident was eventually hospitalized with an unstageable pressure ulcer, revealing lapses in the facility's adherence to pressure ulcer prevention and management policies.
The facility failed to follow physician orders for bolus feeding for a resident and did not document medication and treatment administration for several residents. This included incorrect administration of Jevity 1.2 and missing documentation for medications like Levothyroxine and Protonix. Staff acknowledged the errors, which were observed over multiple days.
The facility failed to ensure accurate dating of physician progress notes for several residents, leading to a deficiency. Residents with various medical conditions had progress notes documented as late entries, indicating a systemic issue with documentation. The facility's policy required physicians to date, write, and sign progress notes at each visit, but this was not adhered to.
The facility failed to issue the required SNF Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents who remained in the facility after their Medicare Part A coverage ended. The Director of Social Services was unaware of the requirement to provide the SNF ABN, resulting in a lack of communication to the residents or their representatives about potential financial liability. This deficiency was noted during a survey and discussed with the facility's administration.
The facility failed to update care plans for two residents, leading to deficiencies in care management. One resident's care plan did not reflect a current physician order for nutritional formula, while another resident's care plan lacked interventions for a newly identified pressure ulcer. These oversights were confirmed by facility staff and highlighted during a surveyor's review.
A facility failed to maintain respiratory equipment in a sanitary manner for a resident receiving continuous oxygen therapy. The resident's oxygen tubing had not been changed since 11/5/24, despite a physician's order for weekly changes. Interviews with staff confirmed the oversight, and the facility's policy also required weekly changes. No further explanation was provided by the facility's administration.
The facility failed to ensure required physician visits and documentation of progress notes for two residents. One resident, admitted with respiratory issues, had no progress notes despite being cognitively intact. Another resident, with heart failure and diabetes, also lacked documentation after the initial admission note. The facility's policy mandates regular physician visits and documentation, which were not adhered to.
A facility failed to timely respond to a Consultant Pharmacist's recommendations for a resident with multiple diagnoses, including anemia and diabetes. The CP advised against crushing Sucralfate tablets and suggested alternative administration methods, but the facility re-ordered the medication without changes. Further recommendations regarding administration timing and evaluation with feedings were also ignored. An LPN continued to crush the tablets for G-tube administration, and the DON admitted to not understanding the CP's advice. The facility's policy lacked a specified timeframe for responding to such recommendations.
The facility failed to properly label, dispose, and secure medications in inspected medication and treatment carts. An unlocked treatment cart was found unattended, and a medication cart contained undated blood glucose test strips and an unnecessary Humalog insulin pen. The LPNs acknowledged these oversights, which were against the facility's medication storage policy.
The facility failed to maintain complete and accessible medical records for two residents, leading to deficiencies in documentation and care coordination. One resident's hospice care binder lacked necessary progress notes, while another resident's physician did not document an admission assessment in the medical records. These actions were contrary to the facility's policies, resulting in incomplete documentation and potential gaps in care management.
Failure to Report and Manage Pressure Ulcer
Penalty
Summary
The facility failed to report and appropriately manage a newly developed pressure ulcer for a resident, leading to the worsening of the condition. The resident, who had a history of Peripheral Vascular Disease and type 2 Diabetes Mellitus with diabetic neuropathy, was admitted with severely impaired cognition. Initially, an excoriation was identified on the resident's sacral area, and treatment with 40% Zinc Oxide cream was ordered. However, there was no documented evidence that the facility reported the development of a pressure ulcer to the wound doctor or updated the resident's medical records accordingly. The facility's records showed inconsistencies and omissions in documenting the resident's condition. Despite the presence of excoriation, the Skin/Wound Note and Progress Notes did not reflect the development of a pressure ulcer. The Pressure Ulcer Flow Sheet also failed to document the excoriation identified earlier. The resident's condition worsened, leading to a new physician's order for a different cream, but the facility did not update the list of residents with facility-acquired wounds to include this resident. Interviews with facility staff revealed that the excoriation was not reported immediately to the wound doctor, which contributed to the worsening of the condition. The facility's policies on pressure ulcer prevention and management, as well as skin checks, were not followed, resulting in a lack of timely intervention and documentation. Ultimately, the resident was transferred to the hospital with a diagnosis of an unstageable pressure ulcer, highlighting the facility's failure to adhere to its own policies and procedures.
Failure to Follow Physician Orders and Document Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of quality in administering tube feeding and documenting medication and treatment for several residents. For one resident, the facility did not follow the physician's order for bolus feeding, administering only one carton of Jevity 1.2 instead of the prescribed two cartons at midnight. This discrepancy was noted over multiple days in November and December, and the error was acknowledged by the facility's staff, including the Registered Dietician and Licensed Practical Nurse. Additionally, the facility failed to document the administration of medications and treatments for four other residents. This included missing signatures on the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for various medications and treatments, such as Levothyroxine, Tylenol, Protonix, and wound care treatments. The lack of documentation occurred on multiple occasions, indicating a pattern of non-compliance with the facility's policy on medication and treatment administration. The surveyor's observations and interviews with facility staff, including the Director of Nursing and Infection Preventionist, confirmed these deficiencies. Despite the facility's policy requiring verification and documentation of medication and treatment administration, the staff failed to consistently adhere to these protocols, resulting in repeated deficiencies in maintaining professional standards of care.
Inaccurate Physician Documentation in Progress Notes
Penalty
Summary
The facility failed to ensure that the primary physicians accurately dated their progress notes during visits, resulting in a deficiency. This issue was observed in 8 out of 16 residents, where the physicians did not document the progress notes on the effective date of service. The residents involved had various medical conditions, including schizophrenia, chronic kidney disease, epilepsy, diabetes, peripheral vascular disease, multiple sclerosis, and dementia, among others. The deficiency was identified through observations, interviews, and record reviews conducted by the surveyors. For Resident #41, the progress notes were not documented on the effective date, with several entries being recorded as late entries. The resident, who was cognitively intact, could not recall the last time they were assessed by their physician. Similarly, Resident #51, who had severely impaired cognition, had multiple progress notes inaccurately dated, with late entries spanning several months. Resident #110, also with severely impaired cognition, had progress notes that were not written on the date of service, indicating a pattern of late documentation. The surveyors also found that Resident #45, who had moderate cognitive impairment, had inaccurately dated progress notes, with several entries recorded as late entries. Resident #66, with moderate cognitive impairment, had a significant number of progress notes inaccurately dated, indicating a systemic issue with documentation. Resident #71, with severe cognitive impairment, and Resident #84, with moderate cognitive impairment, also had inaccurately dated progress notes. The facility's policy required physicians to date, write, and sign progress notes at each visit, but this was not adhered to, leading to the deficiency.
Failure to Issue SNF ABN to Residents
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents who were reviewed during the survey. The SNF ABN is essential for informing beneficiaries about their potential financial liability for services not covered by Medicare and their standard claim appeal rights. The surveyor found that the facility did not provide the SNF ABN to Resident #30, Resident #83, and Resident #27, who were discharged from Medicare Part A coverage but remained in the facility. The Director of Social Services (DSS) had filled out a form titled SNF Beneficiary Notification Review, which indicated that the SNF ABN was not provided to these residents, and there was no additional documentation about the communication of these forms to the residents or their representatives. During an interview, the DSS admitted to the surveyor that he was unaware of the requirement to issue the SNF ABN when residents remain in the facility after Medicare Part A's last covered day of service. The DSS acknowledged that he did not issue the SNF ABN to the residents or their representatives. The surveyor discussed these concerns with the facility's Licensed Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing, but no additional information was provided. This deficiency was noted under NJAC 8:39-4.1(a)(8).
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, leading to deficiencies in their care management. Resident #51, who was admitted with conditions including anemia, type 2 diabetes, and a nontraumatic subdural hemorrhage, had a physician order for Jevity 1.2 formula feeding that was not updated in the care plan. The Registered Dietician acknowledged the oversight, as the care plan still reflected an outdated order for Jevity 1.5. This discrepancy was noted during a surveyor's review of the resident's medical records and was confirmed in an interview with the Registered Dietician. Resident #110, admitted with peripheral vascular disease and diabetic neuropathy, had a newly identified unstageable pressure ulcer on the buttocks that was not reflected in the comprehensive care plan. The care plan failed to include interventions for the pressure ulcer, despite physician orders for topical treatments. The Director of Nursing stated that nurses were responsible for updating care plans, but the facility's policy required audits to ensure care plans were current. The surveyor's review highlighted the lack of updates in the care plan, which was confirmed during a meeting with facility leadership.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for a resident receiving continuous oxygen therapy. The deficiency was identified when a surveyor observed the resident using oxygen via a nasal cannula with tubing that had not been changed since 11/5/24, despite a physician's order to change the oxygen setup weekly. The resident, who was cognitively intact, had been admitted with diagnoses including pneumonia, chronic respiratory failure, and pulmonary fibrosis. Interviews with facility staff, including the LPN/Unit Manager and the Infection Preventionist/Assistant Director of Nursing, confirmed that the oxygen tubing had not been changed according to the physician's order. The facility's policy on oxygen administration also required weekly changes of the oxygen tubing and mask/cannula. Despite discussions with the Licensed Nursing Home Administrator, Director of Nursing, and Infection Preventionist/Assistant Director of Nursing, no further information was provided to explain the failure to adhere to the policy and physician's order.
Failure to Conduct Required Physician Visits and Document Progress Notes
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes as required. This deficiency was identified for two residents. Resident #95, who was admitted with diagnoses including pneumonia, chronic respiratory failure, and pulmonary fibrosis, did not have any Physician Progress Notes (PPN) documented since admission. Despite being cognitively intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), there were no PPNs found in the resident's hybrid medical records. The Licensed Practical Nurse Unit Manager confirmed the absence of PPNs and noted a change in the primary physician from MD#2 to MD#1, effective 11/15/24. MD#2, who was responsible for the resident's care, last visited the facility in October 2024 but could not explain the lack of documentation. Similarly, Resident #103, admitted with chronic systolic heart failure, type 2 diabetes mellitus, and hypertension, also lacked PPNs since admission. The resident, who was cognitively impaired with a BIMS score of 7 out of 15, had only an initial physician's admission note dated 10/2/24, with no subsequent PPNs documented. The facility's policy requires physicians to see residents within 30 days of admission and at least every 30 days for the first 90 days, then every 60 days thereafter. The Director of Nursing acknowledged the documentation concern but provided no further information.
Failure to Respond to Pharmacist's Recommendations
Penalty
Summary
The facility failed to respond to the Consultant Pharmacist's (CP) monthly recommendations in a timely manner for a resident. The resident, who was admitted with multiple diagnoses including anemia, type 2 diabetes mellitus, nontraumatic subdural hemorrhage, and gastrostomy, had a physician's order for Sucralfate to be administered via G-tube. The CP recommended not to crush the Sucralfate tablets and suggested preparing a slurry or changing to a suspension formulation. Despite this, the facility re-ordered the medication without changes and did not respond to the CP's recommendations. Further recommendations by the CP included administering Sucralfate on an empty stomach and evaluating its use with feedings due to the risk of bezoar formation. The facility did not respond to these recommendations either. During an interview, an LPN described crushing the tablets and administering them via G-tube, contrary to the CP's advice. The Director of Nursing (DON) admitted to not understanding the CP's recommendation. The facility's policy did not specify a timeframe for responding to CP recommendations, contributing to the deficiency.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label, dispose, and secure medications in one of five medication carts and one of five treatment carts inspected. During an observation of medication administration, a treatment cart on the 1st floor was found unlocked and unattended, containing ointments and creams. Although no residents were near the cart at the time, the LPN acknowledged that the cart should always be locked when unattended. Additionally, during an inspection of a medication cart on the 1st floor, an opened bottle of blood glucose test strips was found without a date, and an unopened Humalog insulin pen was also undated. The LPN confirmed that the blood glucose test strips should have been dated upon opening, and the Humalog pen should have been dated once removed from the refrigerator. The Humalog pen was also noted to be unnecessary as the resident was no longer on this medication. The manufacturer's specifications indicated that the blood glucose test strips expire 90 days after opening, and the Humalog insulin pen expires 28 days after opening.
Deficiencies in Medical Record Maintenance and Hospice Coordination
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents, leading to deficiencies in documentation and coordination of care. For one resident, the surveyor observed that the hospice care binder lacked progress notes from hospice nurses and aides, which were supposed to be included according to the facility's policy. The Licensed Practical Nurse acknowledged the absence of these notes, and the Hospice Registered Nurse/Director of Operation confirmed that while notes were entered into the hospice's electronic system, they were only printed and filed in the binder if action was required by the facility. The facility's policy required communication and documentation of hospice interventions, which was not adhered to in this case. For another resident, the surveyor found that the resident's primary physician had not documented an admission assessment in the hybrid medical records. The resident, who had moderate cognitive impairment, could not recall their last visit with the physician. The Licensed Practical Nurse unit manager was unsure where the physician documented their progress notes, and the physician later confirmed that the admission assessment was kept in their office rather than in the resident's medical records. This was contrary to the facility's policy, which required that all physician assessments be included in the medical records. The survey team discussed these concerns with the facility's Licensed Nursing Home Administrator and Director of Nursing, who acknowledged the issues. The facility's policies on coordination of hospice services and maintenance of medical records were not followed, resulting in incomplete documentation and potential gaps in resident care management.
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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) |
|---|---|---|---|---|
| Complete Care At Wayne Hills Rehab & Resp Center | 1.1 mi | ★★★★★ | 18 | 0 |
| Arbor Ridge Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Careone At Wayne | 1.4 mi | ★★★★★ | 8 | 0 |
| Atrium Post Acute Care Of Wayneview | 2 mi | ★★★★★ | 1 | 0 |
| Oakland Rehabilitation And Healthcare Center | 2.2 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.