Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Improper Glove Use During Meal Preparation: Kitchen staff were observed preparing resident meal trays with the same gloved hands after touching other kitchen surfaces and equipment away from the tray line. An employee touched resident food on plates after handling other items, and the DM was also observed touching a hamburger bun, opening the warmer door, and then touching the bun again with the same gloves. The DM stated staff should change gloves when leaving the tray line and return with clean gloves.
The facility failed to provide basic grooming and nail care for four residents who needed help with ADLs. Two residents had visible facial hair that was not removed despite repeated observations and staff confirmation that it was a hygiene and dignity issue. Two other residents had fingernails that were too long, and one had black substance under the nails; records showed they did not refuse care, and staff confirmed the nails needed trimming and cleaning.
The facility failed to properly document and monitor psychotropic medication use for two residents. One resident with dementia and hospice care had PRN lorazepam ordered without the required 14-day stop date or documented duration for continued use beyond 14 days, and the record showed only intermittent administration. Another resident with dementia and behavioral disturbance received routine antipsychotic medications, but the chart lacked specific target behaviors and routine behavior monitoring documentation, and staff were unsure what behaviors were being tracked.
Failure to timely report an allegation of mental abuse to the SSA. A cognitively intact resident stated he/she felt mentally abused because the facility held his/her mental health medications, and there was no documentation of the allegation. The Administrator and DON said the allegation was not reported because they believed it was related to medications, despite the facility policy requiring alleged abuse to be reported immediately to the Administrator/designee and to other officials, including the State survey and certification agency.
A resident with dementia and severe cognitive impairment was wearing a wander guard despite MDS assessments showing no wandering behavior and chart notes lacking documentation of wandering or exit-seeking. The care plan and MD orders continued the device, while staff interviews confirmed the resident walked the unit but was not exit seeking and that behaviors were not always documented.
Failure to Assess Alternatives Before Side Rail Use: The facility used side rails for two residents without documenting that alternatives were explored first. One resident had severe cognitive impairment, no side rail care plan, and incomplete bed rail assessments, while another resident with severe cognitive impairment had side rails listed as an enabler in the care plan but no current physician order for bed rail use. Observations showed both residents in bed with side rails in place, and staff stated alternatives were not attempted before bed rail use.
A resident with dementia and severe cognitive impairment had an order for lorazepam 0.5 mg q4h PRN for anxiety without the required stop date. The Consultant Pharmacist identified the missing duration on repeated monthly pharmacy review reports, but the facility did not correct the order or otherwise resolve the irregularity noted in the pharmacy reports.
Expired medications and biologicals were found in three medication storage rooms and one medication cart, including sterile foam tipped applicators, safety syringes, COVID-19 antigen self-tests, vitamins, cyclosporine ophthalmic emulsion, and morphine oral predose syringes. An LPN confirmed the items were expired, and both Central Supply and the Administrator stated it was not acceptable to have expired medications or biologicals in the facility. Facility policy required checking expiration dates and removing outdated items.
Failure to Use Required PPE During EBP: An RN was observed providing close contact care to a resident with a PEG tube in an EBP room while wearing gloves but no gown, touching the resident’s stomach area and PEG tube, and changing gloves without sanitizing hands first. The RN stated he/she had not received infection control or EBP training and did not believe a gown was needed, while the IP and DON stated gowning, gloving, and hand hygiene were required for this type of care.
Inadequate Staff Training on Infection Control and EBP: The facility failed to maintain an effective training program for new and existing staff, including agency personnel. RN2 had no documentation of infection control or EBP training, and both RN2 and CNA1 stated they had not received facility training on infection prevention. The IP said agency staff were only given verbal instruction without formal documentation, while the DON stated staff caring for residents on EBP must use gowning, gloving, and hand hygiene.
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.
Improper Glove Use During Meal Preparation
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions, including proper glove use, during tray line preparation in the kitchen. During observation, a kitchen employee was seen wearing gloves while preparing resident food trays, then touching other items in the kitchen, including opening and closing the warmer and touching other surfaces away from the tray line, before returning to the tray line and touching food on resident plates with the same gloves. The employee stated gloves needed to be changed when they touched other things before returning to food preparation. In a separate observation, the Dietary Manager was preparing a resident's hamburger and, with the same gloved hands, touched the hamburger bun, opened the warmer door to retrieve the hamburger, and then touched the bun again to place the hamburger on it. The Dietary Manager later stated staff should change gloves when they move away from the tray line to do other tasks and put on clean gloves when returning.
Failure to Provide Basic Grooming and Nail Care
Penalty
Summary
The facility failed to ensure facial hair was removed for two residents who required assistance with personal hygiene. One resident with Parkinson’s disease, dementia, lack of coordination, and severe cognitive impairment was assessed as needing total staff assistance with personal hygiene, yet observations on multiple days showed hair at the corners of the mouth and upper lip and slight stubble on the chin. The resident did not refuse care or hygiene tasks, and both an RN and a unit clerk confirmed the facial hair was present and stated it was a hygiene and dignity concern that should have been removed. The facility also failed to ensure fingernails were kept clean and trimmed for two residents who needed help with grooming. One resident with type 2 diabetes mellitus with complications, arthritis in the hands, and upper extremity impairment stated that staff would not trim the fingernails, which were observed to be about one-fourth inch long. Another resident with Parkinson’s disease, Alzheimer’s disease, dementia, severe cognitive impairment, and dependence for personal hygiene was observed with fingernails about one-fourth inch long and black substance underneath them on multiple observations. Record review showed both residents had care plans and MDS assessments indicating a need for assistance with personal hygiene, and task records showed they did not refuse nail care or hygiene care. During interview, RN3 confirmed the fingernails were too long and needed trimming for hygiene purposes, and confirmed the diabetic resident’s nails needed to be trimmed by a nurse. The facility policy stated CNA staff were to provide ADL care including grooming and following the resident plan of care.
Unnecessary Psychotropic Medication Documentation and Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication had the required clinical indication and duration documented beyond 14 days for a resident with unspecified dementia and agitation who was on hospice care. The resident was admitted with a diagnosis of unspecified dementia, later placed on hospice for comfort care, and had an order for lorazepam 0.5 mg every four hours PRN for anxiety. The order did not include a 14-day stop date, and although the resident’s representative signed consent for the medication, the record did not show the required duration for continued PRN use beyond 14 days. Record review showed the resident’s quarterly MDS indicated severe cognitive impairment with a BIMS score of 3 out of 15, no behaviors indicating harm to self or others, and hospice status. The MARs for December 2025 through June 2026 showed the PRN lorazepam was not administered in several months and was given on a few isolated dates in March, April, and May 2026. During interview, an RN stated the lorazepam was intended to ease anxiety and that hospice ordered it, but he/she had not alerted the physician or hospice to review pharmacy recommendations. The pharmacist stated PRN psychotropic medications were expected to have an initial 14-day end date and then be re-evaluated by the prescriber, but the record review showed the prescriber documented a clinical rationale without documenting duration for continued PRN use. The facility also failed to document target behaviors for a resident receiving routine antipsychotic medications for dementia with behaviors. The resident’s record showed diagnoses including unspecified dementia with behavioral disturbance and routine orders for quetiapine 100 mg twice daily and 100 mg at bedtime. Review of the MARs and nursing notes for several months showed no documented evidence identifying the specific target behaviors associated with the antipsychotic use and no documented target behaviors related to the dementia diagnosis. Staff interviews reflected uncertainty about which behaviors were being treated, and the DON stated that target behaviors should be specific to each resident and that staff were expected to monitor them.
Failure to Timely Report Allegation of Mental Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported timely to the State Survey Agency for one resident. The resident was admitted on 06/06/26, and the admission MDS dated 05/13/26 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact. During an interview on 06/01/26 at 10:36 AM, the resident stated he/she felt mentally abused because the facility held his/her mental health medications, and there was no documentation related to this allegation. During an interview on 06/03/26 at 1:35 PM, the Administrator and DON stated the allegation was not reported to the SSA because they believed it was related to the resident's medications. The Administrator stated he/she typically reported all allegations of abuse to the SSA timely. The facility policy titled, Abuse, Neglect, and Mistreatment of Residents Policy, dated 05/26, defined mental abuse as including humiliation, harassment, threats of punishment or deprivation and stated that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property, would be reported immediately to the Administrator/designee and to other officials in accordance with State law through established procedures, including the State survey and certification agency.
Wander Guard Used Without Supporting Documentation
Penalty
Summary
The facility failed to ensure a resident was appropriately screened and had documentation to support the use of a wander guard. The resident had diagnoses including unspecified dementia, muscle weakness, and cognitive communication deficit, and a BIMS score of 3 out of 15 indicating severe cognitive impairment. The resident’s care plan, dated 10/02/24, identified risk for wandering and elopement and included interventions to place a wander guard on the right wrist, but there were no updates to the care plan after that date. Physician orders dated 05/28/25 directed staff to apply the wander guard to the right wrist and check placement and function every shift. Review of the resident’s MDS assessments and elopement risk assessments showed no wandering behavior documented on the quarterly assessments, while elopement risk assessments continued to score the resident as at risk for elopement. General notes from 09/01/25 through 06/01/26 contained no documentation of wandering or exit-seeking behaviors. During survey observations, the resident was seen wearing the wander guard and walking in the room and hallway. Staff interviews confirmed the resident liked to walk around, but several staff stated the resident was not exit seeking and had no documented wandering behavior; one LPN stated staff did not always document wandering or exit-seeking behaviors, and the DON stated it was unclear how anyone would know what staff were observing if those behaviors were not documented.
Failure to Assess Alternatives Before Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were explored before side rails were used for two residents. One resident had diagnoses including unspecified dementia and lack of coordination, with a BIMS score of 3 indicating severe cognitive impairment. The resident's care plan did not address side rail use, and the physician order dated 07/22/25 included half side rail use for positioning. The admission/readmission assessment and a later bed rail assessment both indicated that side rail assessment was not completed, and a quarterly assessment documented no evidence that alternatives were explored before bed rail use. During observation, the resident was in bed with the head of bed upright and side rails up on both sides. Another resident had diagnoses including muscle wasting and atrophy and a BIMS score of 0, indicating severe cognitive impairment and severe impairment with cognitive skills for daily decision making. The care plan stated the resident used side rails as an enabler, with interventions to use side rails for turning and repositioning in bed, but the physician orders did not show a current order for bed rail use. During observation, the resident was resting in bed with side rails on both sides at the top portion of the bed. Staff interviews revealed that side rail assessments were completed on admission, that residents and families would verbalize if they wanted side rails, and that alternatives were not attempted prior to bed rail use. The DON stated staff should be completing alternatives and using the least restrictive measure, and noted many beds already had side rails attached.
Failure to Address PRN Psychotropic Medication Irregularity
Penalty
Summary
The facility failed to ensure that medication irregularities identified during the Consultant Pharmacist’s monthly drug regimen review were addressed for one resident receiving lorazepam. The resident was admitted with a diagnosis of unspecified dementia with agitation and had a quarterly MDS showing a BIMS score of 3 out of 15, indicating severe cognitive impairment. The physician order dated 12/12/25 included lorazepam 0.5 mg every 4 hours as needed for anxiety, and the order did not include a 14-day stop date. The facility’s Nursing Summary Reports dated 01/02/26, 02/04/26, 03/04/26, 04/06/26, and 05/08/26 each documented that the Consultant Pharmacy alerted the facility that a duration must be specified for PRN psychoactive medications and that the first order is limited to 14 days unless the prescriber documents a rationale for a longer duration. During interviews, the Pharmacy Owner/Pharmacist stated that if the Consultant Pharmacist could not obtain an end date on a PRN psychotropic medication, the issue would be escalated to the DON, and the DON stated that the facility addressed clinical issues each morning to ensure physician orders were signed on the pharmacy reports. The facility policy stated that the Consultant Pharmacist conducts monthly and targeted drug regimen reviews, identifies unnecessary drug usage, and submits irregularity reports to clinical leadership.
Expired medications and biologicals found in storage rooms and medication cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles when surveyors found expired items in medication storage areas and a medication cart. During an observation with an LPN, all three medication storage rooms contained expired Medline sterile foam tipped applicators and expired Medline safety syringes, and the first- and second-floor medication storage rooms also contained expired Osang Healthcare COVID-19 antigen self-tests, expired One A Day vitamins, and expired cyclosporine ophthalmic emulsion. The first-floor medication cart contained expired morphine oral 5 mg predose syringes. The LPN confirmed at the time of observation that the syringes, collection tubes, and COVID-19 tests were expired. In interviews, Central Supply stated it was not acceptable to have expired biologicals in the facility, especially in that amount, and the Administrator stated it was not acceptable to have expired biologicals and/or medications in the facility. Facility policy reviewed by surveyors stated that outdated or deteriorated medications or biologicals should be handled through the dispensing pharmacy and that medications should be checked for expiration before administration.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff wore appropriate PPE in a room with Enhanced Barrier Precautions for Resident 83, who was in bed and had a PEG tube. During an observation, RN2 was administering medications and checking the resident’s PEG tube while wearing gloves but no gown, pulling back the resident’s blankets, and leaning across the resident while touching the stomach area and PEG tube. RN2 removed gloves, put on another pair without sanitizing hands first, and then exited the room and sanitized hands only after reaching the medication cart outside the door. During interviews, RN2 stated he/she was an agency nurse and had not received training from the facility or the agency related to infection control or EBP. RN2 stated he/she did not think a gown was needed because he/she was not changing the PEG tube and could not explain why the door sign indicated gowns were required for close contact care. The IP stated staff must gown and glove before providing care to a resident with a G-tube and must wash hands before and after changing gloves and entering and exiting the room. The DON stated staff providing close contact care to a resident on EBP must gown and glove and should practice hand hygiene between glove changes and when finished. The facility policy stated EBP uses targeted gown and glove use during high-contact resident care activities and listed feeding tubes as an indwelling medical device example.
Inadequate Staff Training on Infection Control and EBP
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, including individuals working under contract and volunteers, consistent with their expected roles. Review of the facility assessment stated that staff training, education, and competencies were generally provided upon hire, during monthly in-services, when concerns were identified, or when new needs were identified based on resident diagnoses or clinical condition. However, review of RN2’s personnel training file showed no documentation of pre-employment training or in-service training related to infection control or enhanced barrier precautions (EBP). Interviews confirmed that RN2, an agency nurse, had not received training from the facility or the agency on infection control or EBP. CNA1, also agency staff, stated the facility checked skills online upon hire but did not provide training because the staff member was already trained, and CNA1 had not been trained on the facility’s infection prevention program. The Infection Preventionist stated agency staff were spoken to verbally, but no formal training documentation was obtained, and comprehensive training was not done because agency staff were only at the facility for a day or so. The DON stated that staff providing close contact care to a resident on EBP must gown and glove and practice hand hygiene between glove changes and when finished, and expected all staff to receive appropriate training as a new hire and ongoing.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,240 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 19 | 0 |
| Arbor Ridge Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 8 | 1 |
| Careone At Wayne | 1.4 mi | ★★★★★ | 7 | 0 |
| Avalon Rehab And Care Center | 2 mi | ★★★★★ | 12 | 0 |
| Oakland Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 0 | 0 |
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