Above 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 Wayne County Care Center during CMS and state inspections, most recent first.
Physical Abuse During Personal Care: A resident with severely impaired cognition and dependence on staff for ADLs reported that a CNA slapped her hands during night-shift personal care and told her, "when we say no we mean no." The resident identified the CNA from photos, and the DON stated the resident's account remained consistent during the investigation. The CNA did not confirm or deny the allegation and had a prior written warning for resident care concerns.
Misappropriation of Resident Medication: A resident with dementia, cognitive communication deficit, anxiety, and depression had clonazepam ordered at bedtime. The MAR showed the dose was administered, but during the narcotic count an LPN and another LPN found the blister pack short one tablet and changed the count sheet to match the pack without notifying the DON. The incident review stated neither LPN knew what happened to the missing tablet.
Failure to Report Misappropriation of Residents' Oxycodone: An LPN tested positive for Oxycodone without an active prescription after being required to complete a urine drug test tied to an earlier incident. The facility continued the original investigation instead of opening a new report for the separate misappropriation event, even though multiple residents had Oxycodone orders and were identified as affected. Facility policy required immediate reporting of abuse, mistreatment, neglect, exploitation, and misappropriation of resident property.
Enhanced Barrier Precautions were not followed during indwelling urinary catheter care for a resident with impaired cognition, an indwelling catheter, and a chronic wound. Two CNAs performed catheter care while an EBP magnet was posted on the room doorframe, but neither donned a gown before starting or completing the care. One CNA later confirmed they should have worn gowns, and the facility policy required targeted gown and glove use during high-contact care for residents with indwelling devices or wounds.
The facility failed to obtain signed authorizations from two residents for managing their funds, affecting their right to manage their financial affairs. The residents had significant balances in their accounts, but there was no documentation of their consent. A fiscal specialist confirmed the absence of authorization forms.
The facility failed to notify two residents when their account balances exceeded the Medicaid limit, risking their benefits. A fiscal specialist confirmed the residents did not receive the required written notification, which is necessary to prevent loss of Medicaid benefits.
A facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident receiving skilled services under Medicare Part A. The resident, with diagnoses including cerebral infarction and hemiplegia, was scheduled for discharge from therapy services, but the NOMNC was not issued due to a misunderstanding by the Social Services Designee about the requirement. This affected one of two residents reviewed for beneficiary notification.
A resident with severe cognitive impairment and multiple medical conditions was found using oxygen tubing that had not been changed in accordance with the facility's policy. The tubing, dated over a week old, was observed during a survey, and the facility's policy required changes every seven days. The DON confirmed the policy, but an attempt to interview the responsible LPN was unsuccessful.
A resident with a history of Alzheimer's and high fall risk suffered a major injury after falling from bed due to inadequate staff assistance. The resident required two-person assistance for bed mobility, but an STNA provided care alone, leading to the fall. The facility's investigation confirmed the STNA did not follow the care plan, resulting in the resident's injuries.
Physical Abuse During Personal Care
Penalty
Summary
The facility failed to ensure a resident was free from staff-to-resident physical abuse. Resident #16 was admitted with diagnoses including traumatic hemorrhage of the cerebrum, leukemia, depression, high blood pressure, and anxiety, and the admission MDS showed severely impaired cognition with a BIMS score of 5 out of 15 and dependence on staff for ADL tasks. During personal care on the night shift, the resident reported that a CNA slapped her hands when she was holding onto the siderail and told her, "when we say no we mean no." The resident was able to identify the CNA from photographs as the person involved in the incident. The resident later confirmed that someone had slapped her hands during care. The DON stated that the resident's account did not change during interviews by other staff members, and during the CNA's interview for the facility investigation, the CNA did not confirm or deny the allegation of physical abuse. The report also notes that the CNA had a prior disciplinary written warning for resident care concerns, including leaving residents on wet bed pads and an unfriendly attitude when answering call lights.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s medication involving Resident #14, who had diagnoses including unspecified dementia, cognitive communication deficit, anxiety, and depression. Resident #14 had a physician order for clonazepam 0.5 mg at bedtime, and the MAR showed the medication was documented as administered on 08/19/25. The narcotic count sheet for clonazepam showed one tablet was administered that evening with eight tablets left in the medication card. During the morning narcotic count on 08/20/25, it was noted that the blister pack should have contained eight tablets but only seven were present. LPN #397 and LPN #401 adjusted the count sheet to reflect one tablet removed and seven tablets remaining, and both signed the entry without notifying the DON about the discrepancy. The facility incident review stated neither LPN knew what happened to the missing clonazepam tablet, and the discrepancy was later reported to the DON, sheriff, and county report of loss process.
Failure to Report Misappropriation of Residents' Oxycodone
Penalty
Summary
The facility failed to report a separate misappropriation incident involving residents' pain medication, Oxycodone, after a drug test for LPN #401 revealed the LPN tested positive for Oxycodone without an active prescription. The incident was identified during review of Facility Reporting Incident #264336, which had originally involved a required urine drug test for Clonazepam. Although the facility continued its investigation under the original report, it did not initiate a new report when the Oxycodone result was received, even though the positive test indicated use of residents' medication. The Director of Nursing confirmed the facility did not open a new FRI after the Oxycodone result was received. Residents #6, #13, #14, #18, #24, #45, and #47 were identified as affected because they had orders for Oxycodone. The facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, stated staff should immediately report such allegations to the Administrator and to the Ohio Department of Health in accordance with the policy.
EBP Not Followed During Catheter Care
Penalty
Summary
Enhanced Barrier Precautions were not followed during indwelling urinary catheter care for one resident. The resident had diagnoses including rectum cancer, high blood pressure, obstructive and reflux uropathy, and epilepsy, and had impaired cognition with a BIMS score of 8 and an indwelling urinary catheter. Physician orders included catheter care every shift and PRN, and Enhanced Barrier Precautions for high contact care related to a chronic wound every shift. The care plan also addressed the indwelling urinary catheter with catheter care per physician orders. During observation of catheter care, two CNAs completed the resident’s indwelling urinary catheter care while a room magnet indicating EBP was present on the doorframe, but neither CNA donned a gown before starting or completing the care. In interview, one CNA confirmed that neither CNA put on gowns before catheter care and stated they should have worn gowns. The facility policy stated that Enhanced Barrier Precautions include targeted gown and glove use in addition to standard precautions during high contact resident care activities for residents with indwelling medical devices or wounds.
Failure to Obtain Authorization for Managing Resident Funds
Penalty
Summary
The facility failed to ensure that residents who wanted the facility to manage their funds had signed authorizations in place. This deficiency affected two residents out of 24 who had resident funds managed by the facility. Specifically, Resident #19 had a balance of $2,210.05, and Resident #37 had a balance of $3,716.61 in their respective resident funds accounts. However, there was no documentation indicating that either resident had signed an authorization form allowing the facility to manage their funds. During an interview with Fiscal Specialist #300, it was confirmed that there were no resident funds authorization forms for these two residents. This lack of documentation indicates a failure to honor the residents' rights to manage their financial affairs, as required by regulations.
Failure to Notify Residents of Medicaid Spend Down
Penalty
Summary
The facility failed to ensure that residents received a spend down notice before reaching the maximum allowed limit for Medicaid benefits, affecting two residents out of 24 with resident funds. Specifically, Resident #19 had a balance of $3,716.61, and Resident #4 had a balance of $4,814.47 in their respective Resident Funds accounts. The facility is required to notify residents when their account balance reaches $200 below the allotted amount of $2000, as exceeding this limit could result in the loss of Medicaid benefits. An interview with Fiscal Specialist #300 confirmed that both Resident #4 and Resident #19 did not receive written notification that their accounts were over the allotted amount, which could impact their Medicaid benefits. The residents should have been informed that they were nearing the limit so they could use their funds or return the excess to Medicaid.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to Resident #41, who was receiving skilled services covered under Medicare Part A. Resident #41 had been admitted with diagnoses including cerebral infarction, hemiplegia, and muscle wasting, and was receiving occupational and physical therapy services. Despite being scheduled for discharge from therapy services, the facility did not issue a NOMNC, as confirmed by the Social Services Designee (SSD) #245, who was unaware of the requirement to provide such notice to individuals receiving Medicare Part A services. The deficiency was identified during a review of Resident #41's medical records and staff interviews. The resident had been receiving extensive therapy services, with recertification assessments confirming coverage through early June. However, the SSD and the Director of Nursing (DON) confirmed that a NOMNC was not issued, as the SSD mistakenly believed it was unnecessary for non-managed care or voluntary discharges. This oversight affected one of the two residents reviewed for beneficiary notification, highlighting a gap in the facility's compliance with Medicare notification requirements.
Failure to Timely Change Oxygen Tubing
Penalty
Summary
The facility failed to change the oxygen tubing in a timely manner for a resident, identified as Resident #8, who was receiving oxygen therapy. Resident #8 had a medical history that included cerebral infarction, type two diabetes mellitus, anxiety, ovarian cancer, hypertension, depression, and hemiplegia and hemiparesis following cerebral infarction. The resident's respiratory care plan indicated a need for oxygen therapy due to potential altered breathing patterns. The physician's orders specified that the oxygen tubing should be changed every Saturday, but the treatment administration record showed that the tubing was last changed on November 9, 2024. On November 12, 2024, an observation revealed that Resident #8 was unresponsive to verbal stimuli and was using oxygen tubing dated November 2, 2024, indicating that the tubing had not been changed as per the facility's policy of changing it every seven days. This was confirmed by a Certified Nurse Aide during an interview. The Director of Nursing also stated that the facility's policy required the oxygen tubing to be changed at least every seven days or as needed. An attempt to interview the LPN responsible for changing the tubing was unsuccessful.
Inadequate Staff Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate staff assistance during resident care, resulting in a fall with major injury for Resident #6. On the morning of 07/24/24, a State tested Nursing Assistant (STNA) #300 was providing incontinence care to Resident #6, who required two-person assistance with bed mobility. During the care, Resident #6 was repositioned onto her right side by STNA #300 without additional staff assistance, contrary to the care plan that required two-person assistance. As a result, Resident #6 kicked her left leg out and began sliding out of the bed, landing on her right side and sustaining multiple injuries, including a fracture to the right femoral neck. Resident #6 had a medical history that included Alzheimer's dementia, stroke, high blood pressure, anxiety, contractures, and osteoporosis, and was assessed as being at high risk for falls. The care plan for Resident #6 specified the need for two-person assistance with bed mobility due to her impaired mobility and high fall risk. Despite these documented needs, STNA #300 attempted to provide care alone, leading to the resident's fall and subsequent injuries. The facility's investigation revealed that STNA #300 did not follow the resident's care Kardex, which outlined the necessary assistance required for safe care. The incident was reported, and the facility conducted an investigation, which included reviewing the medical records, staff interviews, and facility policies. The investigation confirmed that the fall was caused by inappropriate assistance provided by STNA #300, who was subsequently suspended pending the investigation. The facility's policy on managing falls and fall risks emphasized the importance of identifying interventions related to specific risks to prevent falls and minimize complications, which was not adhered to in this case.
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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 Wooster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glendora Health Care Center | 2.4 mi | ★★★★★ | 3 | 0 |
| Wooster Community Hospital Snf | 3.1 mi | ★★★★★ | 0 | 0 |
| West View Healthy Living | 4.2 mi | ★★★★★ | 0 | 0 |
| Smithville Western Care Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Avenue At Wooster | 5.2 mi | ★★★★★ | 4 | 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.