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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wayne Center For Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide requested medical records to two residents or their representatives within the required timeframe. One cognitively intact resident with DM and CAD requested paper copies, but staff delayed release while discussing HIPAA paperwork, charges, and internal review; the records were not provided until weeks later. Another resident with COPD and dementia had a representative request records after a fall, but the request was routed through corporate compliance and delayed pending proxy authorization before the records were finally released.
Failure to Resolve Grievance About Missing Personal Property: A resident with CHF, CAD, CVA, and severely impaired memory had a family representative report missing shoes and other personal items, including food stored in a refrigerator. Although the concern was brought to staff and the social worker was notified, there was no documented investigation or written outcome in the record, and the representative stated prior concerns had not been believed or resolved.
A CNA left a severely confused, restless resident alone during a bed transfer to get supplies, and the resident attempted to self-transfer and fell while trying to get into bed. The CNA then grabbed and placed the resident back onto the bed without first notifying the RN or obtaining an assessment. The resident later developed pain and swelling, and x-rays showed a subtrochanteric hip fracture that required hospital transfer and surgical repair.
A resident with CHF, CAD, and a CVA had a family-requested transfer to another facility, and Social Services discussed the transfer process and faxed PRI-related documents to a prospective facility. However, the record lacked documentation of follow-up on the transfer request, the status of placement efforts, or communication of updates to the family member after the resident’s family said the resident did not feel safe in the facility.
The facility did not maintain its fire extinguishing system as required by 2011 NFPA 25 standards. During a survey, it was found that fire hoses in three stairwells had not been tested or replaced within the required five-year period. The hoses were last stamped in April 2014, and the facility's Administrator confirmed the oversight.
The facility experienced significant staffing shortages, particularly on weekends and night shifts, affecting resident care. Residents reported delays in receiving assistance, and staff struggled to manage their workload. The administration acknowledged challenges in maintaining adequate staffing levels due to competition and high callout rates.
The facility failed to adhere to professional standards for food storage and safety, as observed during a survey. Expired and improperly labeled food items were found in the dairy walk-in refrigerator and pantry units. Staff interviews revealed lapses in oversight and adherence to food safety policies, with responsibilities not consistently executed by the Dietary Supervisor, RNs, and other staff members.
The facility failed to maintain sanitary conditions in garbage storage areas. A dietary aide transported an uncovered garbage can through the food prep area, and the outside compactor lid was left open. The facility's policy requires covered receptacles and closed compactor lids, but there was no evidence of monitoring compliance.
A resident with impaired cognition did not receive proper monitoring and maintenance of a peripheral intravenous site, as required by facility policy. The dressing was not dated or changed every 72 hours, and there was no documentation of site assessment prior to removal. Interviews revealed that staff failed to follow procedures, leading to a deficiency in care.
A resident with severe cognitive impairment and dependence on a ventilator fell out of bed and sustained a skin tear when a CNA provided care alone, contrary to the care plan requiring two-person assistance for bed mobility. The CNA reported that the system indicated only one-person assistance was needed, and they did not have time to call for help when the resident became agitated.
A resident with multiple diagnoses, including Osteoporosis, did not have a comprehensive care plan for Osteoporosis after returning from hospitalization. The RN Manager stated the care plan was not reactivated, and the DON noted it was mentioned in the Pain/Discomfort care plan, but this was not reflected in the surveyor's copy.
The facility failed to update the Comprehensive Care Plans for two residents as required. A resident in a persistent vegetative state had a care plan last reviewed in August 2024, despite needing total care. Another resident on oxygen therapy had a care plan that was not updated quarterly. Interviews revealed a lack of clarity and responsibility among staff regarding care plan updates.
Two residents in an LTC facility received inappropriate respiratory care. One resident used oxygen without a medical order, while another used undated nasal cannula tubing, exceeding the prescribed oxygen flow rate. The facility failed to document oxygen administration and equipment changes, violating established protocols.
The facility's Medical Director did not attend the required QAPI quarterly meetings, as confirmed by attendance records and interviews. The facility's policy mandates the Medical Director's participation, but they were too busy to attend and were briefed afterward. This absence constitutes a deficiency in compliance with the facility's policy.
Delayed Release of Resident Medical Records
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided copies of health care records within two working days after a written request and advance notice to the facility. This deficiency involved two residents out of the sample reviewed: one resident requested medical records and did not receive them until about two weeks later, and another resident’s representative requested records and did not receive them until more than two weeks later. The facility policy stated that clinical information should be released in a timely manner, within two business days. Resident #15 was cognitively intact and had diagnoses including diabetes mellitus and coronary artery disease. The resident requested medical records and presented a completed request form to the surveyor, but there was no documented evidence that the records were provided within two working days. A care plan note documented that the resident requested a copy of medical records and was given HIPAA consent paperwork to sign, while the social worker stated the resident never returned the form. Other staff stated the resident requested paper copies, was told there could be a charge for a large amount of paper, and that the records were ultimately given on 06/09/2026 after the request on 05/25/2026. Resident #117 had diagnoses including COPD and dementia, and the MDS documented moderately impaired cognition with the representative participating in assessment. The representative requested medical records after a fall and stated they received them about a month later. Staff stated the request was routed through corporate compliance and that a health care proxy authorization was needed before release; the administrator stated the request was received on 05/29/2026 and the records were picked up on 06/15/2026 after the representative said they did not have the proxy authorization. The facility’s process described multiple internal approvals before release, and staff gave differing time frames for how long the request should take.
Failure to Resolve Grievance About Missing Personal Property
Penalty
Summary
The facility failed to make prompt efforts to resolve a grievance involving missing personal property for one resident. The facility policy required grievances to be investigated within 48 hours and for both the resident and complainant to receive written notification of the outcome, but there was no documented evidence that the resident’s representative’s concern about missing items was investigated or resolved. The grievance involved missing shoes and other personal belongings, and the resident’s representative reported that items had disappeared from the resident’s closet, including shoes, clothing, and food stored in the dining room refrigerator. Resident #131 had diagnoses including CHF, CAD, and CVA, and the quarterly MDS documented severely impaired memory, need for supervision during chair-to-bed transfers, and participation of the family representative in assessment and goal setting. The resident was observed alert, awake, seated in a wheelchair, and confused, able to respond to name and engage in minimal conversation. The resident’s representative stated that items were labeled when brought to the facility and that nursing staff maintained a record of items provided, but also reported repeated losses of shoes and prior discussions with the social worker without being believed. An RN stated the family representative reported the missing shoes and that an email with the handwritten note was sent to the social worker, while the social worker stated there was no documentation in the medical record regarding the outcome or resolution of the concern.
Failure to Supervise a Confused Resident During Transfer
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for one resident who was severely confused, restless, agitated, and at high risk for falls. The resident’s assessment showed severely impaired memory and a need for supervision when transferring from a chair to bed. The care plan documented that the resident constantly tried to get out of bed, slid from the wheelchair, and required fall precautions, including close monitoring for unsafe behaviors and redirection as needed. On the day of the incident, a CNA wheeled the resident to the room and then left to get additional supplies, despite the resident’s known confusion and unsafe transfer behaviors. While the CNA was away, the resident attempted to transfer independently from the wheelchair to the bed and fell while trying to get into bed without assistance. When the CNA returned, the resident was halfway to the floor; the CNA grabbed the resident and placed them back onto the bed. The CNA later stated the resident had a history of propelling themselves in and out of the wheelchair or attempting to move independently, and that the resident should have been more closely monitored. After the event, the resident complained of left thigh and hip pain, with swelling and tenderness noted. X-rays showed a subtrochanteric fracture of the left hip, and the resident was later transferred to the hospital and underwent surgical repair with an intramedullary nail. The DON stated staff should not lift a resident after a fall and should notify the RN, and also stated the appropriate practice would have been to gather all supplies before beginning care. The facility investigation concluded the fracture likely occurred when the CNA lifted and swung the resident toward the bed during the attempted rescue.
Failure to Document Follow-Up on Resident Transfer Request
Penalty
Summary
Medically related social services were not fully provided to support Resident #131’s transfer request and communication with the receiving facility. Resident #131 had diagnoses including congestive heart failure, coronary artery disease, and cerebrovascular accident, and the quarterly MDS documented severely impaired memory, supervision needed for transfers from chair to bed, and family representative participation in assessment and goal setting. The resident was observed alert, awake, seated in a wheelchair, and confused, able to respond to name and engage in minimal conversation. The social services record documented that the resident’s representative requested transfer to another facility and was informed of the transfer process. The representative stated they would provide names of facilities to explore, and later the resident’s family requested that the PRI and additional required documentation be faxed to a nursing facility for review. A nursing progress note also documented that the resident’s family member reported the resident did not feel safe in the facility and requested transfer, with Social Services to be contacted for follow-up. However, the medical record contained no further documentation of follow-up on the transfer request, the status of the transfer to other facilities, or how updates were communicated to the resident’s family member.
Failure to Maintain Fire Extinguishing System
Penalty
Summary
The facility failed to ensure that all components of the building's extinguishing system were tested and maintained in accordance with the 2011 NFPA 25 standards. During a life safety survey conducted on January 16, 2025, it was observed that the fire hoses located in the facility's three stairwells, specifically on the 11th floor and the basement, were stamped with a date of April 2014. There was no evidence that these hoses had been tested or replaced within the five years prior to the survey. This deficiency was confirmed through staff interviews, where the facility's Administrator acknowledged the oversight and stated that the hoses would be replaced.
Plan Of Correction
Plan of Correction: Approved January 23, 2025 Immediate Corrective Action Safety Fire Sprinkler company inspected the stairwell fire hoses on 1/23/2025 and sent a proposal to supply and replace by 2/28/2025, 24 - 1.5 x 25' rack fire hose with NYFD couplings and 48 - 1.5 x 50' rack fire hoses with NYFD couplings. Identification of Other Residents All residents were potentially affected by this deficiency. Systemic Changes The Administrator reviewed and revised the fire safety policy to include bi-annual inspections on all stairwell fire hoses. The Director of Environmental Services will add to the preventive maintenance schedule a bi-annual inspection on all stairwell fire hoses. The Director of Environmental Services will ensure, as part of the preventive maintenance schedule, to have all fire hoses tested by the fire sprinkler company once every 5 years. Quality Assurance The Administrator will review the fire prevention preventive maintenance book for fire hose inspections every 6 months and will report the findings during the quarterly QAPI committee meeting. All negative findings will be addressed immediately.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, particularly on weekends, as evidenced by the Recertification Survey conducted from January 13, 2025, to January 21, 2025. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 indicated excessively low weekend staffing, particularly on the 2nd Floor ventilator unit. The facility's staffing schedule revealed a consistent pattern of shortages, especially during the night shift, with multiple instances of missing Licensed Practical Nurses and Registered Nurses. Interviews with residents and staff highlighted the impact of these staffing shortages on resident care. Several residents reported delays in receiving assistance, such as waiting hours for a new gown or help to the bathroom, and experiencing long response times to call bells. A resident's relative also noted that the resident often required incontinence care upon their visits, indicating a lack of timely care. Certified Nursing Assistants reported being overwhelmed with the number of residents they were responsible for, leading to difficulties in ensuring all residents were clean and dry by the end of their shifts. The facility's administration acknowledged challenges in maintaining adequate staffing levels, citing competition with other facilities, union restrictions, and high callout rates among Certified Nursing Assistants. The Director of Nursing admitted to inflating staffing ratios in the facility assessment to secure additional budget but believed the facility was safely staffed. Despite these assertions, the survey findings and resident interviews suggest that the staffing levels were insufficient to meet the residents' needs, particularly during weekends and night shifts.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, observations in the kitchen and pantry revealed several deficiencies. In the dairy walk-in refrigerator, there were opened and expired loaves of bread and bags of rolls. Additionally, two of the six pantry unit refrigerators contained expired milk, spilled and spoiled food items, and undated and unlabeled food items. The facility's policies and procedures for food storage and safety were not adhered to. The policy required that all dry goods be stored in a safe environment, with new stock placed behind old stock to ensure the First In-First Out method. However, the Dietary Supervisor admitted to missing expired bread items during weekly inspections because they were stored in an undated, unlabeled box on the top shelf. Similarly, the pantry refrigerators were found to be overpacked with improperly labeled or unlabeled food items, and the responsibility for maintaining these standards was not clearly executed by the staff. Interviews with staff, including the Dietary Supervisor, Director of Food Service, Registered Nurses, and the Director of Nursing, revealed a lack of consistent oversight and adherence to the facility's food safety policies. The staff acknowledged their roles in checking and maintaining the refrigerators but admitted to oversights and failures in executing their responsibilities. The facility administrator indicated a need for follow-up with the food service director to address these findings.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain sanitary conditions in the garbage storage areas, as observed during a recertification survey. Specifically, during a kitchen observation, a dietary aide was seen transporting an uncovered garbage can from the outside trash compactor through the food preparation area while lunch was being prepared. The facility's policy requires that solid waste be transported in covered receptacles, and the outdoor compactor lid must remain closed except when in use. However, the dietary aide admitted to not covering the garbage can because they were in a rush, and the dietary supervisor confirmed that the garbage can should have been covered to prevent unsanitary conditions. Additionally, an observation of the outside garbage compactor revealed that its lid was left open and uncovered, contrary to the facility's policy. The dietary supervisor acknowledged that the compactor lid should be kept closed when not in use. There was no documented evidence of monitoring trash containment or disposal, and the Food Service Director had no comments on the findings, indicating a lack of oversight in ensuring compliance with the facility's waste management procedures.
Failure to Monitor and Maintain Peripheral Intravenous Site
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically in the monitoring and maintenance of a peripheral intravenous site. Resident #187, who was admitted with diagnoses including Hypertension and Peripheral Vascular Disease, had severely impaired cognitive skills for daily decision-making. The resident was observed multiple times with an undated dressing covering a left upper extremity peripheral intravenous catheter, indicating a lack of adherence to the facility's policy and procedure for intravenous therapy. The facility's policy required that intravenous tubings and dressings be labeled with the date and time of change, and that the insertion site be observed for signs of complications every 72 hours. However, there was no documented evidence that the peripheral intravenous line dressings were changed or that the insertion site was assessed prior to January 16, 2025. The physician's orders for the administration of intravenous fluids and antibiotics were not accompanied by corresponding orders for dressing changes until January 16, 2025, despite the initiation of intravenous therapy on January 11, 2025. Interviews with Registered Nurse #4 and the Director of Nursing revealed that the dressing at the insertion site had not been changed since the start of the intravenous infusion, and the dressing was not dated as required. The nurse responsible for the insertion failed to date the dressing, and subsequent staff did not observe or document the need for a dressing change. The Director of Nursing acknowledged that the dressing should be changed every three days, and that the nurse manager should verify this during daily rounds and through the Treatment Activity Report. This oversight resulted in a deficiency in the care provided to Resident #187.
Resident Falls Due to Inadequate Assistance During Care
Penalty
Summary
The facility failed to ensure a resident remained free from accident hazards, as evidenced by an incident involving a resident who fell out of bed and sustained a skin tear to the forehead. The resident, who had diagnoses including Hemiplegia or Hemiparesis and was dependent on a ventilator, required two-person assistance for bed mobility according to their care plan. However, during care, a certified nursing assistant (CNA) provided assistance alone, contrary to the care plan requirements. The CNA turned the resident, who then became agitated and fell out of bed, resulting in a 2.5 cm skin tear on the forehead. The facility's policy on accident prevention was not adhered to, as the CNA did not follow the prescribed care plan that required two-person assistance for bed mobility. The CNA reported that the computer system indicated only one-person assistance was needed, and they did not have time to call for additional help when the resident became agitated. The incident was reported to the nursing supervisor, and the resident was assessed and treated for the injury. The facility's investigation concluded that the CNA did not intentionally harm the resident, but the incident met the criteria for Department of Health reporting due to the failure to follow the care plan.
Failure to Reactivate Osteoporosis Care Plan Post-Hospitalization
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented for a resident diagnosed with Osteoporosis. The resident, who had multiple diagnoses including Dementia with Psychosis, Alzheimer's Disease, Hypertension, Bipolar Disorder, Seizure Disorder, Chronic Obstructive Pulmonary Disease, and Osteoporosis, was admitted with physician orders for each condition. However, despite having care plans for other conditions, there was no care plan specifically addressing the resident's Osteoporosis. This oversight was identified during a recertification survey. The Registered Nurse Manager acknowledged that the Osteoporosis care plan had been in place since 2020 but was not reactivated after the resident's hospitalization in 2023. The Director of Nursing explained that care plans are typically reinstated upon a resident's return from the hospital, but in this case, the Osteoporosis care plan was not reactivated. The Director also noted that the Osteoporosis diagnosis was mentioned in the Pain and Discomfort care plan, although this was not reflected in the surveyor's copy of the plan of care.
Failure to Update Comprehensive Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that residents' Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, including quarterly review assessments. Specifically, Resident #74's Self-Care Comprehensive Care Plan was last reviewed on August 1, 2024, and was not updated quarterly as required. Resident #74, who is in a persistent vegetative state with severe cognitive impairments, requires total care for activities of daily living and is dependent on staff for all needs. Despite the facility's policy mandating quarterly reviews, there was no documented evidence that the care plan was reviewed and revised after the October 29, 2024, assessment. Interviews with the Director of Nursing, Director of Rehab, and a Registered Nurse revealed a lack of clarity and responsibility regarding the updating of care plans, contributing to the oversight. Similarly, Resident #187, who has severely impaired cognitive skills and is maintained on oxygen therapy, had an Alteration in Cardiopulmonary Care Plan that was not updated quarterly. The care plan, last reviewed on August 26, 2024, did not reflect any revisions or updates following the October 4, 2024, assessment. The Director of Nursing acknowledged that care plans are supposed to be reviewed quarterly but did not provide an explanation for the failure to update Resident #187's care plan. This deficiency was identified during a recertification survey, highlighting the facility's non-compliance with its own policies and regulatory requirements.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their treatment. Resident #19, who was admitted with diagnoses including Non-Alzheimer's Dementia and Seizure Disorder, was observed using oxygen via nasal cannula at 2 liters without a medical doctor's order. Despite being on oxygen since returning from the hospital, there was no documented order until 01/14/2025. The oversight occurred because the nurse who initially administered the oxygen did not document the order, and subsequent staff did not verify the presence of an order. Resident #187, admitted with diagnoses including Hypertension and Peripheral Vascular Disease, was observed using undated nasal cannula tubing for oxygen administration at 5 liters per minute, which exceeded the physician's order of 2-3 liters per minute as needed. The facility's records lacked documentation of oxygen administration or tubing changes for January 2025. The unit manager acknowledged the failure to date and change the tubing weekly, as required by the facility's policy. These deficiencies highlight lapses in following established protocols for oxygen administration and documentation. The facility's policies require that oxygen orders be documented and that equipment be changed regularly to prevent infection. However, these procedures were not adhered to, resulting in unapproved oxygen use and potential infection control issues.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director participated in the Quality Assurance and Performance Improvement (QAPI) quarterly meetings, as required by their policy. The QAPI program is designed to provide a systematic approach to monitor and improve the facility's performance. The facility's policy mandates that the QAPI Committee includes the Medical Director, among other key staff members. However, the review of attendance sheets for the last four quarterly meetings revealed that the Medical Director did not attend any of these meetings. Interviews with the Medical Director and the Administrator confirmed that the Medical Director was too busy to attend, and instead, they were briefed on the meeting discussions afterward. The facility's QAPI Committee documentation did not list the Medical Director as a member, contrary to the policy requirements. The Administrator acknowledged the absence of the Medical Director from the meetings and stated that meeting notes were sent to the Medical Director post-meeting. The Medical Director confirmed that they did not attend the meetings but were briefed by the Director of Nursing. This lack of participation by the Medical Director in the QAPI meetings constitutes a deficiency as it does not align with the facility's policy and regulatory requirements.
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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 Bronx
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bainbridge Nursing & Rehabilitation Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Mosholu Parkway Nursing & Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Beth Abraham Center For Rehabilitation And Nursing | 0.6 mi | ★★★★★ | 1 | 0 |
| St Patrick's Home | 0.7 mi | ★★★★★ | 3 | 0 |
| Bronx Park Rehabilitation & Nursing Center | 0.7 mi | ★★★★★ | 1 | 0 |
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