Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Woodlands Manor during CMS and state inspections, most recent first.
Failure to Timely Assess and Address Significant Weight Loss: The facility did not consistently monitor and respond to significant weight changes for three residents with nutritional risk. One resident with dementia, depression, and feeding difficulties had a 7% weight loss followed by further decline, but the RD assessment was delayed and ordered supplements were not shown as implemented. Two other residents had large, fluctuating weight losses, lacked timely RD assessments and required reweights, and one remained underweight despite supplements and continued decline.
A resident with moderate cognitive impairment and a PRN order for alprazolam 1 mg for anxiety received the medication on nine occasions, but the clinical record did not document any non-pharmacological interventions before administration. The DON confirmed the record lacked documentation of attempted non-pharmacologic measures prior to the psychotropic medication use, contrary to facility policy and federal requirements.
Inaccurate MDS Assessments for Two Residents: The facility failed to ensure MDS assessments accurately reflected the status of two residents. One resident with COPD had an MDS that incorrectly documented a trunk restraint when observations did not show any device restricting body access, and another resident with metabolic encephalopathy had an MDS that incorrectly reported no falls despite a documented fall in the clinical record. The NHA and DON confirmed the MDS data was inaccurate.
A resident with COPD and moderate cognitive impairment had a pain care plan for degenerative joint disease, but it did not include the implanted spinal cord stimulator used for pain management, the location of the device remote, or the need for the remote to accompany the resident to device-related appointments. The DON confirmed the care plan lacked these resident-centered interventions, even though the remote had been provided to the family and later left the facility with them.
Pain medication was not administered according to physician-ordered pain scale parameters for a resident with low back pain and moderate cognitive impairment. MAR review showed Oxycodone 5 mg was given for pain ratings above the ordered range and Oxycodone 10 mg was given for a pain rating below the ordered range, with no documentation that the resident requested an alternate medication choice. The DON acknowledged the orders were not followed and the record did not support alternative-medication requests.
Failure to Provide Behavioral Health Care for Resident Grief: A resident with Lewy body dementia and severe cognitive impairment developed grief-related behaviors after learning of her sister’s death, including yelling at staff and attempting to hit staff. The record contained only a RD note linking poor intake to grief, with no social work or psych notes and no care plan addressing grief or the resident’s psychosocial symptoms.
Failure to Prevent and Assess Pressure Injuries: The facility did not prevent a pressure injury from developing under a loose knee immobilizer for one resident with a femur fracture, PVD, and limited mobility, and it did not complete timely, thorough wound assessments or document ordered wound care before the CRNP later identified a Stage III PI. For another resident with MS and dementia, staff identified a buttock pressure area but did not document a complete RN wound assessment or required witness statements, and the CRNP later classified the wound as a Stage II PI.
Call Bell System Not Functioning: The facility failed to maintain a working resident call bell system for several halls. Observation showed multiple active call lights with no audible alert, and staff said they could only notice requests by visually checking the door lights. An employee reported the sound worked only sometimes, and the NHA acknowledged the system had been known to malfunction, with no alternate resident alert method provided while the system remained out of service.
Controlled substance documentation did not reconcile with the MAR for a resident with spinal stenosis and an open leg wound who had orders for Tramadol and later Oxycodone for pain. Multiple doses were signed out on the controlled substance record without matching MAR entries, one dose was documented on the MAR without a matching sign-out, and the DON confirmed the discrepancy.
An LPN was observed with a medication cart containing five opened multi-dose insulin pens, including Humalog, Novolog, and Novolog 70/30, that were available for resident use but not dated to show when they were first opened. The facility policy required the date opened to be recorded on multi-dose containers, and the LPN confirmed the pens lacked opening dates; the DON was later interviewed about the labeling failure.
Failure to Offer Bedtime Snacks: The facility did not consistently offer a bedtime snack even though the interval between the substantial evening meal and breakfast exceeded 14 hours. Residents reported that no evening snack was provided, and the NHA could not produce documentation showing that snacks were consistently offered as required by the facility snack policy.
Two residents did not receive individualized pain management consistent with professional standards, as staff failed to attempt non-pharmacological interventions before administering as-needed pain medications and repeatedly gave pain medications outside of prescribed pain scale parameters without documenting clinical reasoning. Orders for medication type, dose, and pain scale were not followed, and non-pharmacological interventions were not documented.
A resident was given antibiotics for a suspected UTI based on abnormal urinalysis results and family request, despite no documented urinary symptoms or clinical criteria being met. The antibiotic was started before culture confirmation and was later found to be ineffective against the identified organism, with the DON confirming that the medication was initiated without proper clinical justification.
A resident with chronic lung disease and muscle weakness experienced pain after a fall and underwent a cervical spine x-ray, which revealed a right-lung infiltrate and recommended a follow-up chest x-ray. The facility did not document that the physician was notified of these abnormal findings or that the follow-up test was completed, and the DON could not explain the lack of communication.
Failure to develop and implement an individualized dementia care plan for a severely cognitively impaired resident with ongoing aggression, intrusive wandering, and resistance to care. The resident had repeated incidents of slapping and grabbing other residents, entering rooms without boundaries, and daily wandering behaviors, but the care plan was not updated with new interventions or documented person-centered strategies to address the behaviors.
The facility did not thoroughly investigate or submit a complete report to the State Survey Agency within the required timeframe after two residents were found to have missing controlled substances following discharge. The initial investigation report was incomplete, lacked necessary documentation, and was not resubmitted after being rejected, with facility leadership unable to provide evidence of a completed investigation.
A resident with cerebral palsy and other conditions suffered a serious injury due to the failure of two agency Nurse Aides to use a Hoyer lift as required by the care plan. Despite being trained, the aides neglected to follow proper transfer protocols, leading to an impacted fracture of the resident's right humerus. The incident was confirmed through internal investigation and interviews with the resident and her roommate.
Wayne Woodlands Manor failed to address resident grievances regarding the inconsistent delivery of fresh water, as reported by six residents during Resident Council meetings. Despite repeated complaints documented in meeting minutes from late 2024 to early 2025, the facility did not provide evidence of corrective actions. Interviews with the NHA and DON confirmed the lack of documented responses to these grievances.
The facility failed to implement its abuse prohibition procedures by not adequately screening five employees, including LPNs, a Nurse Aide, a Dietary Aide, and the DON. The facility did not document contacting former employers to verify past employment, as required by their policy. This was confirmed by the Administrator, indicating a failure to adhere to the facility's own procedures.
The facility failed to provide timely and necessary behavioral health care to two residents with dementia, leading to a deficiency in maintaining their mental and psychosocial well-being. Both residents exhibited escalating behaviors, but their care plans were not updated, and no follow-up interventions were implemented despite worsening symptoms. The NHA could not provide evidence of psychological services aimed at improving the residents' well-being.
A facility failed to prevent the misappropriation of narcotic medications for a resident with chronic pain. Despite receiving a delivery of Tramadol, the medication went missing the same day. An LPN signed for the delivery and informed another LPN of the medication's location, but it was left unattended. Video footage showed unsecured handling of the medication cart. The facility's investigation lacked witness statements and failed to identify the perpetrator, although the resident did not miss any doses.
A facility failed to prevent urinary tract infections for a resident with an indwelling catheter. The resident's care plan did not document the use of a leg bag for daytime urinary drainage, and the urinary drainage bag was improperly stored, posing a risk for cross-contamination. The DON confirmed the lack of adherence to infection control guidelines and absence of staff education on urinary drainage system care.
A resident with multiple diagnoses, including cerebral palsy and contractures, did not receive effective pain management as the facility failed to attempt non-pharmacological interventions before administering pain medication. Despite having a comprehensive care plan, the resident was repeatedly given medication without prior non-pharmacological attempts, as confirmed by the DON.
A facility failed to provide a written notice of a hospital transfer to a resident and their representative, as required by regulations. The deficiency involved a resident with atrial fibrillation, heart disease, and a fracture, who was transferred to the hospital and later readmitted. The facility did not document that the resident's responsible party was informed in writing about the transfer, as confirmed by the Administrator.
The facility did not report cases of Influenza A to the appropriate health agencies for 13 residents who tested positive. The infection control documentation showed positive tests over several weeks, and staff confirmed that the required notifications were not made.
A resident with cognitive impairment was sexually assaulted during the night shift in an LTC facility. The resident reported the incident to a nurse aide, and a subsequent hospital examination confirmed injuries consistent with sexual assault. The facility's investigation revealed that a male agency nurse aide was on duty during the incident, but the resident could not identify the assailant due to darkness. The facility failed to protect the resident, resulting in psychosocial harm.
The facility failed to provide abuse prevention training to agency nursing staff, including an agency nurse aide and an agency RN. The staffing coordinator confirmed that while credentials are verified, abuse training is not requested. The facility relies on agency staff for adequate staffing but lacks evidence of abuse training for them.
A resident reported an alleged sexual assault to a nurse aide, but the facility failed to conduct a thorough investigation. The resident, who was moderately cognitively impaired, was sent to the hospital, but the facility did not interview all staff on duty or document a completed investigation. The DON confirmed the lack of investigation and documentation.
A facility failed to update a care plan for a resident with dementia, leading to an incident where the resident exhibited aggressive behavior during an outing with her son. The care plan did not address the resident's aggressive tendencies, and the son was unprepared to manage the situation, resulting in physical injuries to the resident.
A resident with moderate cognitive impairment reported a sexual assault incident to a nurse aide, which was then reported to an LPN and the DON. Attempts to assess the resident were unsuccessful due to her distress. The incident was not fully documented in the clinical records, as confirmed by the DON, indicating a failure to maintain complete and accurate records.
A resident with dementia and severe cognitive impairment was allegedly abused by a nurse aide, who was reported to have held the resident by their sweater and screamed at them. Despite the incident being witnessed by other staff, the facility failed to report the alleged abuse to the State Survey Agency within the required 24-hour period, as per their policy. The report was only made after surveyor inquiry, highlighting a deficiency in the facility's abuse reporting procedures.
A facility failed to promptly investigate and report an alleged abuse incident involving a resident with dementia. A nurse aide was reported to have physically and verbally abused the resident, but the facility did not follow its abuse prevention policy. Although the aide was initially removed, she returned to duty without a completed investigation, and the incident was not reported to the State Survey Agency within the required timeframe.
The facility failed to provide restorative nursing services and devices to maintain mobility and range of motion for a resident with difficulty in walking, abnormal posture, osteoarthritis, and muscle weakness. Despite recommendations for a restorative nursing program and a physician's order for an ankle stirrup, the facility did not implement the RNP or apply the ankle support, as confirmed by observations and staff interviews.
The facility failed to maintain infection control practices for three residents, including those with urinary tract infections, pressure ulcers, and indwelling catheters. Observations revealed the absence of Enhanced Barrier Precautions (EBP) and improper handling of medical supplies, confirmed by the Director of Nursing and Nursing Home Administrator.
A resident with Parkinson's disease experienced a significant weight loss of 12.4% over six months. Although the attending physician was notified, there was no documented evidence that the resident's representative was informed. This deficiency was confirmed during an interview with the Nursing Home Administrator.
A resident with Parkinson's disease experienced a 12.4% weight loss over six months, but the facility's care plan did not address this decline in nutritional status. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to timely identify, assess, and treat pressure sores for two residents. One resident with a history of hypertension, diabetes, and heart failure had an untreated pressure sore on the right buttock, while another resident with a hip fracture and dementia developed a pressure wound due to inconsistent monitoring of a knee immobilizer. These deficiencies were confirmed through clinical record reviews, staff interviews, and observations.
The facility failed to administer oxygen as ordered and maintain sanitary oxygen delivery systems for a resident with COPD and respiratory failure. Observations revealed undated nasal cannula tubing and the resident not receiving oxygen as prescribed. Interviews confirmed non-compliance with physician orders and facility policy.
Failure to Timely Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to consistently assess, monitor, and respond to significant weight changes for three residents with nutritional risk. Facility policies required routine weight monitoring, reweights within 24 to 48 hours for significant changes, review of intake and other contributing factors, physician notification, and interdisciplinary assessment when clinically significant weight loss or gain occurred. The record review showed that comprehensive nutrition assessments were not completed annually for the affected residents, and the documented weight changes were not timely evaluated when they first occurred. Resident 1 had diagnoses including dementia, depression, and feeding difficulties, and was documented as having moderate cognitive impairment and needing set-up assistance for meals. The resident had a nutrition-at-risk care plan, but the most recent comprehensive nutrition assessment was completed in October 2024, with no comprehensive RD assessment completed during 2025. The resident’s weights showed a significant loss of 10.2 pounds, or 7 percent, over 36 days, followed by additional loss of 5 pounds within 9 days. The record did not show timely assessment of the initial loss or timely development of additional nutritional interventions when the weight decline continued. A later RD note documented continued weight loss and recommended a nutritional juice supplement twice daily, but the record did not show physician or responsible party notification for the continued loss, a physician order for the supplement, or evidence that the supplement was implemented. Resident 41’s record also lacked an annual comprehensive nutrition assessment, with the last one completed in February 2025. The resident had highly variable recorded weights, including a loss of 8.3 pounds, or 9.3 percent, in one month, and later additional significant losses of 11.1 percent and 15 percent over short intervals. The record did not show reweights were obtained as required to verify the accuracy of the fluctuating weights. The RD note was completed 18 days after the initial significant loss and identified the resident as underweight with a BMI of 16.9, but the record still failed to show timely assessment and intervention when the weight loss was first identified. Resident 28 had a nutrition-at-risk care plan, but the record did not show a comprehensive RD nutrition assessment to evaluate nutritional and hydration status. The resident experienced a significant weight loss of 16.6 pounds, or 15.3 percent, within about one month. The RD note addressing the loss was completed 13 days after the loss had been identified and documented that the resident remained on a regular diet, had adequate fluid intake, and was receiving high-calorie, high-protein supplements and frozen supplements, yet the resident remained underweight with a BMI of 17.1. The record did not show that the significant weight loss was timely assessed when first identified. During interview, the Nursing Home Administrator confirmed there was no additional documentation showing that Resident 28’s weight loss had been thoroughly assessed by an RD or that interventions had been timely developed and implemented.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to document the use of non-pharmacological interventions before administering a PRN psychotropic medication for one resident. Resident 101 was admitted with a diagnosis of instability of the internal right knee prosthesis and had an admission MDS dated May 7, 2026 showing a BIMS score of 12 and moderate cognitive impairment. The resident had a physician order dated May 7, 2026 for Alprazolam 1 mg every six hours as needed for anxiety. The resident's MAR showed Alprazolam 1 mg was administered nine times between May 10, 2026 and May 19, 2026. Review of the clinical record did not identify documentation that non-pharmacological interventions were attempted before these administrations. During an interview on May 21, 2026, the DON confirmed that the record did not contain documentation of non-pharmacologic interventions prior to the psychotropic medication being given on those nine occasions, as required by federal requirements and facility policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ status for two residents reviewed. The RAI Manual requires MDS assessments to accurately reflect functional status and be completed with participation from appropriate health professionals, but the facility coded inaccurate information in the assessments for Resident 3 and Resident 26. Resident 3 was admitted with COPD and had a quarterly MDS that documented moderate cognitive impairment with a BIMS score of 8. The same assessment, in section P, indicated the resident used a trunk restraint when out of bed; however, observations on May 19, 2026, in the dining room and on May 20, 2026, in the activities room did not show any device restricting access to the resident’s body. Resident 26 was admitted with metabolic encephalopathy and had a quarterly MDS showing cognitive impairment with a BIMS score of 3. The assessment, in section J, documented no falls since the prior assessment, but the clinical record showed the resident experienced a fall on February 23, 2026. During an interview on May 20, 2026, the NHA and DON reviewed the information and confirmed the MDS data was inaccurate.
Failure to Include Implanted Spinal Cord Stimulator in Pain Care Plan
Penalty
Summary
The facility failed to develop and maintain a comprehensive, person-centered care plan that accurately reflected Resident 3’s pain management needs and interventions. Resident 3 was admitted with COPD and had moderate cognitive impairment on the quarterly MDS, with a BIMS score of 8. The current comprehensive care plan, initially developed on June 17, 2025, included a problem related to pain associated with degenerative joint disease and a goal of effective pain relief, but it did not identify the resident’s implanted spinal cord stimulator, the location of the device remote, or the need for the remote to accompany the resident to appointments related to the device. A nursing progress note documented that the resident’s family requested the remote control for the spinal cord stimulator, the remote was provided, and the family later reported it would not power on and left the facility with the device. A physician order dated April 21, 2026, scheduled the resident for an appointment on May 26, 2026, with a consulting physician for evaluation of the spinal cord stimulator. During interview, the DON stated the resident had an implanted spinal cord stimulator used for pain management, that the remote was stored in the medication room, and that it was required to accompany the resident to appointments involving evaluation or management of the device. The DON confirmed the comprehensive, resident-centered care plan did not include the implanted spinal cord stimulator or related care-planning interventions.
Pain Medication Administered Outside Physician-Ordered Pain Scale Parameters
Penalty
Summary
Facility staff failed to follow physician-ordered pain medication parameters for one resident with muscle weakness and low back pain. The resident was admitted to the facility and, on the April 22, 2026 MDS, was documented as moderately cognitively impaired with a BIMS score of 12. Physician orders included Oxycodone 5 mg every 6 hours as needed for moderate pain rated 4 through 6, and Oxycodone 10 mg every 6 hours as needed for severe pain rated 7 through 10. An additional order stated that if the resident requested pain medication with a lower pain scale than the resident's reported pain level, staff could administer the medication of the resident's choice. Review of the April and May 2026 MARs showed Oxycodone 5 mg was administered 17 times, including 4 times when the documented pain rating was above the ordered range for that dose: pain ratings of 7 on April 21, April 25, and April 27, and a pain rating of 8 on May 9. The MARs also showed Oxycodone 10 mg was administered 20 times, including once on May 17 when the documented pain rating was 3, below the ordered range for that dose. The clinical record contained no documentation that the resident requested a different pain medication than the one specified for the documented pain rating. During interview, the DON acknowledged staff did not administer the medications according to the physician-ordered pain scale parameters and that the record lacked documentation supporting resident requests for alternative pain medication.
Failure to Provide Behavioral Health Care for Resident Grief
Penalty
Summary
The facility failed to ensure that Resident 41 received necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being. Resident 41 was admitted with diagnoses including neurocognitive disorder with Lewy body dementia and was severely cognitively impaired on the Quarterly MDS, with a BIMS score of 3. The record showed that the resident experienced grief after learning of her sister’s death, and a roommate reported that Resident 41 had been exhibiting new behaviors, including attempting to hit staff and yelling at staff, related to that loss. The clinical record contained only one note addressing the resident’s loss, which was a nursing progress note by the Registered Dietician stating that the resident’s recent poor intake could potentially be related to grief. There was no documented evidence that behavioral health services were provided for the grief, no social service notes, no psychological services notes, and no care plan for grief. The resident’s care plan did not address the specific mental health concern or psychosocial symptoms, and the NHA was unable to provide evidence that Resident 41 was receiving psychological services to maintain the highest practicable level of mental and psychosocial well-being.
Failure to Prevent and Properly Assess Pressure Injuries
Penalty
Summary
The facility failed to prevent the development of pressure injuries and failed to perform timely and thorough assessments of pressure injuries for two residents. Resident 55 was admitted with a right distal femur fracture, cerebral infarction, peripheral vascular disease, and generalized muscle weakness. The resident’s admission MDS showed cognitive intactness, wheelchair use, and dependence for several ADLs. The care plan identified risk for impaired skin integrity due to decreased mobility and directed staff to use a low air loss mattress, treat any injury per facility protocol, and identify and document causative factors. A DON note documented that the right leg brace was very loose on admission and a smaller brace was obtained from therapy, but the facility could not provide evidence of physician orders for the immobilizer at admission or documentation that the skin beneath the immobilizer was routinely monitored. Staff discovered a new open area beneath the brace on Resident 55’s right calf during evening care. The wound was initially documented as unknown in cause, with the resident stating it hurt when touched. The wound was cleansed and dressed, and the physician was notified. A nursing note later described the wound on the rear aspect of the right lower leg as 7.0 cm by 8.0 cm by 0.8 cm with rancid odor and drainage, but the stage was recorded as not applicable. The physician ordered daily wound care and a wound care specialist appointment, yet the TAR showed no evidence that licensed nursing staff completed the ordered wound treatments the following day. Five days after the wound was found, the contracted CRNP assessed it as an in-house acquired Stage III pressure ulcer measuring 3.0 cm by 1.5 cm by 0.20 cm. The facility could not provide documented evidence that the wound was thoroughly assessed or staged by nursing staff before the CRNP assessment. Resident 49 had diagnoses including multiple sclerosis and dementia. A readmission evaluation documented a pressure area of the left buttock and bruising, but no additional skin assessments were documented after that evaluation until a later progress note identified a pressure area on the right buttock. The RN documented the area as pressure in nature and noted pressure reduction items and turning and repositioning, but the wound observation did not include a complete assessment, including depth, surface area calculations, wound characteristics, or staging. Three days later, the contracted CRNP assessed the wound as a Stage II pressure ulcer measuring 0.3 cm by 0.6 cm by 0.1 cm. The facility could not provide documentation of a timely and thorough RN assessment at identification or the witness statements required by policy from staff caring for the resident within 24 hours of identification.
Call Bell System Not Functioning
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system that would allow residents to directly and promptly request assistance from staff in the bathroom and bathing areas on three of four halls, including Green Hall, Mauve Hall, and Blue Hall. A review of the facility policy titled Call Light and Procedure, last reviewed in January 2025, showed that staff were responsible for responding to call bells and reporting defective call lights to the nurse supervisor, with hand bells to be provided to residents when the main system did not work. During observation on November 17, 2025, multiple call bell lights were illuminated on Mauve Hall, Blue Hall, [NAME] Hall, and Peach Hall, but there was no audible alert for any of the active call bells. Staff stated they could only identify a resident request by visually noticing the small light above the room door while standing in the hallway. An employee reported that the system sometimes activated sound but not often, and the NHA acknowledged the facility had known about the malfunction, planned to replace the system in 2026, and had purchased handheld bells previously, but residents had not been provided with them or any other alternate method to call for assistance. The facility was unable to provide documentation of a work order or repair request for the ongoing malfunction, despite prior knowledge that the system was not functioning as intended.
Controlled substance records did not reconcile with MAR documentation
Penalty
Summary
The facility failed to implement effective procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one resident. A facility policy on controlled substances required compliance with laws and regulations related to handling, storage, disposal, and documentation of Schedule II narcotics, and stated that the DON or designee would audit narcotics received using signed invoices and pharmacy printouts. The resident had diagnoses including spinal stenosis and an unspecified open wound of the lower left leg, and had physician orders for Tramadol HCL 25 mg every six hours as needed for severe pain and later Tramadol HCL 50 mg every six hours as needed for moderate pain. A review of the resident’s Controlled Substance Record and MAR showed multiple discrepancies between doses signed out and doses documented as administered. For Tramadol 25 mg, there were 10 entries on the Controlled Substance Record without corresponding MAR documentation, one date with two sign-outs but only one MAR entry, and one MAR entry without a matching sign-out. For Tramadol 50 mg, there were additional entries signed out without MAR documentation across September and October. The record review also found two Oxycodone HCL 5 mg entries signed out without MAR documentation. During an interview, the DON confirmed that the documentation did not reconcile between the Controlled Substance Record and the MAR for the resident.
Multi-dose insulin pens were left undated in a medication cart
Penalty
Summary
The facility failed to follow acceptable storage and labeling practices for multi-dose medications in one medication cart on the Blue Hall C Unit. Review of the facility’s Medication Administration policy, last reviewed in January 2025, indicated that the expiration date or beyond-use date on a medication label must be checked before administration and that when a multi-dose container is opened, the date opened must be recorded on the container. Multi-dose medications are intended for more than one dose and must be dated when first opened so staff can determine when they expire and whether they are safe to use. On November 20, 2025, at 8:25 AM, an observation of the Blue Hall C Unit medication cart in the presence of an LPN revealed two opened Humalog insulin pens, two opened Novolog insulin pens, and one opened Novolog 70/30 insulin pen that were available for resident use but were not dated to show when they had been initially opened. The LPN confirmed that the five insulin pens were opened and available for resident use without any date indicating when they were first opened. The DON was interviewed later that morning regarding the facility’s failure to follow acceptable storage and labeling practices for multi-dose medications.
Failure to Offer Bedtime Snacks
Penalty
Summary
The facility failed to ensure that residents were consistently offered a nutritious evening snack during the time between dinner and breakfast. A review of the facility’s Snack Policy showed that snacks were to be offered three times daily, including at H.S. (bedtime), but the scheduled meal times showed that the interval between the substantial evening meal and breakfast exceeded 14 hours in multiple care areas. Dinner was served between 4:45 PM and 5:25 PM depending on the unit, and breakfast was served between 7:10 AM and 7:45 AM the next morning, creating overnight gaps of 14 hours 15 minutes to 15 hours. During a resident council interview, 6 of 6 residents who desired a bedtime snack stated that an evening snack was not offered and that they did not receive a snack before bedtime. During a later interview, the Nursing Home Administrator was unable to provide documentation showing that evening snacks were consistently offered to residents. The deficiency was cited for residents 35, 47, 50, 51, 51, and 75.
Failure to Follow Pain Management Protocols and Physician Orders
Penalty
Summary
The facility failed to develop and implement individualized pain management programs consistent with professional standards of practice for two residents. Clinical record reviews revealed that staff did not attempt non-pharmacological interventions prior to administering as-needed pain medications, despite explicit physician orders requiring such interventions. Additionally, staff repeatedly administered pain medications outside of the prescribed pain scale parameters and did not document clinical reasoning for these deviations. For one resident with diagnoses including spinal stenosis and an open wound, physician orders specified the use of acetaminophen for mild pain and tramadol for moderate to severe pain, with clear instructions to attempt non-pharmacological interventions before medication administration. However, documentation showed that tramadol was administered multiple times for pain ratings below the ordered threshold, and non-pharmacological interventions were not attempted or documented. There were also instances where the incorrect dose of tramadol was given, and acetaminophen was not administered as ordered during certain periods. Another resident with chronic obstructive pulmonary disorder and muscle weakness had an order for hydrocodone/acetaminophen to be given for pain rated 1-5. Despite this, the medication was administered on numerous occasions for pain ratings above the ordered range, with over 40 instances documented outside the provider's parameters. There was no documentation explaining the clinical reasoning for these actions. Interviews with the DON confirmed the findings related to the failure to follow physician orders, lack of non-pharmacological interventions, and inconsistency with professional standards of pain management.
Unnecessary Antibiotic Administration Without Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, as required by their Antibiotic Stewardship Program policy. The policy mandates that clinical symptoms of infection must be present before collecting cultures or starting antibiotics, and that empiric antibiotics should only be initiated if the resident meets specific clinical criteria and appears systemically ill. In the case reviewed, a resident with chronic obstructive pulmonary disorder and muscle weakness was administered Macrobid for a suspected urinary tract infection (UTI) at the request of the family, despite multiple progress notes and standardized urinary change forms documenting no signs or symptoms of a UTI. The resident's clinical record did not contain documentation of urinary symptoms that would meet the criteria for starting empiric antibiotic therapy, nor was there evidence that McGeer's criteria were met. The resident received two doses of Macrobid before laboratory confirmation of infection and before sensitivity results were available, which later showed resistance to Macrobid. The antibiotic was started solely based on abnormal urinalysis results and family request, without supporting clinical evidence or symptoms. The Director of Nursing acknowledged that antibiotics were initiated prior to culture confirmation and in the absence of documented clinical symptoms, contrary to facility policy and established infection surveillance criteria.
Failure to Promptly Notify Physician of Abnormal Diagnostic Results
Penalty
Summary
The facility failed to ensure that laboratory and diagnostic test results were promptly communicated to the ordering physician for a resident. The resident, who had a history of chronic obstructive pulmonary disorder and muscle weakness, was admitted to the facility and had intact cognition as assessed by a BIMS score of 13. Following a fall, the resident experienced uncontrolled head and neck pain, prompting a cervical spine x-ray. The x-ray, completed later that day, revealed an apparent right-lung infiltrate and recommended a follow-up chest x-ray for further evaluation. A review of the clinical record showed no documentation that the physician was notified of the abnormal x-ray findings or that the recommended follow-up chest x-ray was completed. During an interview, the DON was unable to provide an explanation for the lack of documentation regarding physician notification or review of the x-ray results. The DON confirmed that it is the facility's responsibility to ensure prompt communication of laboratory and diagnostic test results to the physician.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered plan of care for a resident with dementia and severe cognitive impairment. Resident 31 was admitted with a diagnosis of dementia, and the Annual MDS dated September 22, 2025, identified the resident as severely cognitively impaired. Nursing progress notes from July 2025 through the end of survey on November 21, 2025, documented ongoing behavioral symptoms including physical and verbal aggression toward residents and staff, intrusive wandering into others’ rooms or personal spaces, and resistance to care, with intrusive wandering occurring almost daily. Facility investigative documentation showed repeated behavioral incidents involving the resident. On July 23, 2025, staff heard yelling and observed Resident 31 slap a roommate, Resident 25; the residents were separated and no injury was noted. On July 26, 2025, staff found Resident 31 in Resident 93’s room, where the resident slapped Resident 93 and poured water on her; no injury was noted. On September 13, 2025, while staff were walking with Resident 31 in the hallway, the resident wandered into Resident 51’s room and grabbed Resident 51’s arm; no injury was noted. The care plan, initially dated July 13, 2025 and last revised August 26, 2025, contained no new interventions in response to the repeated aggressive behaviors, intrusive wandering, or resistance to care, and there was no documented evidence of an individualized, person-centered dementia care plan or individualized strategies to manage or reduce the behaviors. The Nursing Home Administrator confirmed on November 21, 2025, that the facility could not provide evidence that such a plan had been developed or implemented.
Failure to Complete and Submit Timely Investigation of Misappropriation Allegations
Penalty
Summary
The facility failed to ensure that all allegations of resident abuse and misappropriation were thoroughly investigated and that complete investigation results were submitted to the State Survey Agency within five working days, as required by policy. Specifically, an incident was reported in which a resident was discharged home with a prescription for Oxycodone, but upon arrival, the responsible party discovered that 11 tablets were missing. The responsible party contacted the facility and spoke with an LPN who had been assigned to the resident on the day of discharge. The LPN stated she had the remaining pills in a prescription bottle, which was not the facility's standard practice, as medications are typically dispensed on a unit-dose card. An internal review also revealed that another resident, recently discharged to the hospital, was missing 32 Hydrocodone tablets, and the required controlled substance sign-out sheets for both residents' medications were missing. Although the facility initiated an investigation and submitted a report through the Electronic Reporting System, the report was incomplete and lacked required supporting documentation such as witness statements and confirmation that all necessary components were included. The incomplete report was rejected by the State Survey Agency, and the facility did not submit a revised, complete investigation for review. During interviews, facility leadership was unable to provide documented evidence that the investigation was completed in full and submitted within the required timeframe.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not utilizing a mechanical lift as planned, resulting in a major injury for a resident. The resident, who had cerebral palsy, dysphagia, contractures, and cerebral infarction, required assistance with activities of daily living and was dependent on staff for transfers. The resident's care plan specified the use of a Hoyer lift for all transfers to ensure safety and prevent injury. On the evening of January 26, 2025, two agency Nurse Aides were providing care to the resident. During this time, the resident began complaining of pain in her right arm, which intensified when her shirt and bra were removed. Despite the resident's care plan requiring the use of a Hoyer lift, the aides failed to use it during the transfer from the wheelchair to the bed. This improper transfer led to a serious injury, an impacted fracture of the right humerus, as confirmed by a mobile x-ray. The facility's internal investigation revealed that both aides had completed training on the proper use of Hoyer lifts and were aware of the facility's abuse and neglect policy. However, they neglected to follow the established protocols, directly leading to the resident's injury. Interviews with the resident and her roommate confirmed that the mechanical lift was not used during the transfer, and the resident experienced significant pain and discomfort as a result.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Upon completion of the facility's investigation, the two nursing assistants, Employee 1 and Employee 2 were DNR (Do Not Rehire) because the CNAs failed to follow the training provided through their certification, agency and facility training regarding proper use of assistive devices for transfers and abuse training. Include on the current nursing assistant Daily CNA Report the names of residents with transfer requirements for the use of lifts, e.g., safety concerns, positioning techniques, and necessary assistive devices. The Daily CNA Report will be signed by the certified nursing assistant and the charge LPN/RN. The report sheets will be given to the RN Supervisor at the end of each shift. All clinical nursing staff will be trained on the proper use of assistive devices for transfers and abuse training. Lift training will focus on hands-on practice and residents with a wide range of limitations. An approved acceptable provider has been selected to direct in-service education for F600. The Interdisciplinary Team will create a list of residents that require the use of assistive lifts for transfers. The facility will implement a system of regular observation of staff, including checking if the correct lift is being used for each resident, proper sling selection and placement, correct operation of the lift, and documenting each lift use, while providing ongoing training and education to staff on safe lift practices and report any concerns regarding lift usage. The Therapy Department will conduct a mandatory education for clinical staff on proper use of assistive devices, including the lifts. Random checks will be conducted by Director of Nursing/designee to ensure proper lift and transfer technique is being followed. All incident reports will be reviewed by the Risk Team to ensure no other evidence of noncompliance of lift usage and/or abuse has occurred. The results of the random audit checks and investigation of incident reports will be presented to QAPI monthly x 12 months.
Failure to Address Resident Grievances on Fresh Water Delivery
Penalty
Summary
Wayne Woodlands Manor was found to be non-compliant with specific requirements of 42 CFR Part 483 Subpart B and the 28 PA Code during a survey completed on February 14, 2025. The facility failed to adequately address and resolve grievances expressed by residents during Resident Council meetings. Specifically, six residents consistently reported issues with the inconsistent delivery of fresh water, a concern that was documented in the minutes of meetings held in November 2024, December 2024, and January 2025. Despite these repeated complaints, there was no documented evidence of corrective actions taken by the facility to address the issue. Interviews conducted with the Nursing Home Administrator and the Director of Nursing confirmed the absence of documented actions to resolve the grievances raised by residents. The facility's grievance policy, last revised in August 2021, states that residents have the right to voice grievances concerning their care and treatment. However, the facility failed to demonstrate efforts to resolve the complaints regarding fresh water delivery, as evidenced by the lack of documentation and the continued dissatisfaction expressed by the residents.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. The facility will review the last three Resident Council Meeting Minutes and identify resident concerns that need to be addressed and follow-up to ensure all concerns have been addressed. A policy review to reflect evidence-based practice and a performance improvement plan will be created to address the resident's concern with fresh water distribution. An audit will be done on each wing daily x 4 weeks. Water distribution will be addressed and reviewed in QAPI x 3 months. An official grievance will be filed for fresh water distribution throughout the facility for any resident who expresses a concern with their water. For Resident #15, the facility will determine her preference for water distribution and ensure her preferences and any other residents with similar issues are accommodated. The Administrative Team will review the last three months of Resident Council Meeting minutes and provide a summation of residents' issues to review with the residents in the next month's meeting. The Activities Director/designee is assigned to the Resident Council Meeting monthly. Upon completion of the meeting, the Activities Director/designee will respond and compile a list of resident issues and/or grievances expressed during the meeting. The administrative staff, to the extent practicable, will consider their recommendations and attempt to accommodate them, including revising or developing new policies related to resident life and care. Any grievances will be investigated by the Grievance Officer. After the meeting, the Activities Director/designee will ask the meeting attendees if they would like to file an official written grievance(s) related to issues discussed during the meeting. The Administrator/designee will ensure all issues addressed by the Resident Council have a documented plan of action written, signed, and dated within one week following the Resident Council concerns. Previous month plan of actions will be discussed with the Resident Council at every Resident Council Meeting by the Activities Director/designee. Following the monthly Resident Council Meeting, the Administrative Team will review concerns brought by the residents at each meeting and perform a random survey of five residents in each wing to ascertain if they are having the same concerns. The Administrative Team will review the Grievance Process. Mandatory training for all staff will be conducted by the social worker on the grievance process. A random water audit will be conducted to ensure fresh water is passed three times daily and the cup contains the initials of the resident, room number, and date. The results of the audit will be present at QAPI monthly x3. The Resident Council minutes will be reported by the Activities Director/designee at QAPI monthly for the next 12 months; concerns will be tracked, and trends will be discussed with the Interdisciplinary Team. The results of the random survey will be monitored for trends and reported to QAPI monthly x 12 months.
Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to fully develop and implement its established abuse prohibition procedures by not adequately screening five employees for employment. The regulatory requirements under §§483.12(a)(3) and 483.12(b)(1) mandate that the facility must have written procedures for screening prospective employees, which include reviewing employment history, obtaining information from former employers, and checking documentation of status and any disciplinary actions from licensing or registration boards. However, the facility's Resident Abuse policy, last reviewed in December 2023, required obtaining references from current or previous employers, which was not adhered to. A review of employee personnel files revealed that for five employees, including two LPNs, a Nurse Aide, a Dietary Aide, and the DON, there was no documentation showing that the facility had contacted any former employers to verify past employment. Interviews with the Administrator confirmed that there was no evidence of previous employers being contacted for information regarding the employees' past work history. This lack of verification indicates a failure to follow the facility's own abuse prohibition policy.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the identified individuals are established employees. For all potential employment candidates, the Human Resources Coordinator will contact former employers for information regarding former employment history and professional references for feedback regarding affirmation of employment. The Human Resources Coordinator will create a spreadsheet to track all new candidates and monitor the receipt of personal and professional employment references monthly. The Human Resources Coordinator will report monthly at QAPI x3.
Failure to Provide Timely Behavioral Health Care
Penalty
Summary
The facility failed to provide timely and necessary behavioral health care to two residents, leading to a deficiency in maintaining their highest practicable mental and psychosocial well-being. Resident 33, admitted with dementia, exhibited behaviors such as yelling, auditory, and visual hallucinations, which increased in frequency and intensity as noted in nursing progress notes from January and February 2025. Despite these observations, the resident's care plan, last revised in October 2024, was not updated to address the worsening symptoms, and no follow-up interventions were implemented after a psychological progress note in January 2025. Similarly, Resident 8, also diagnosed with dementia, showed behaviors including yelling, restlessness, anxiety, aggression, and crying, which escalated in early 2025. The resident's care plan, last updated in September 2024, did not reflect these changes, and no additional psychological interventions were documented following a psychological evaluation in January 2025. The Nursing Home Administrator was unable to provide evidence of psychological services aimed at maintaining or improving the residents' mental and psychosocial well-being, highlighting a failure to update care plans and provide necessary psychological services.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Review and update Resident #33 and Resident #8 care plans to reflect any changes in behavior to ensure all interventions are person-centered based on behaviors identified. An audit will be conducted, by Social Services or designee, on all residents exhibiting behaviors to ensure individualization of person-centered care plans. All new residents, with diagnoses reflecting behavioral issues or concerns, will have individualized, person-centered care plans. The residents will be reviewed at the weekly Behavioral Meeting. Social Services will present and report at monthly QAPI monthly x3.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to implement procedures to prevent the misappropriation of resident property, specifically narcotic medications, for one resident. Resident 16, who was admitted with multiple rib fractures, a periprosthetic fracture, and dysphagia, had a physician order for Tramadol 50mg for chronic pain. On January 27, 2025, the pharmacy delivered 30 tablets of Tramadol 50mg to the facility for Resident 16, but the medication card and sign-out sheet went missing the same day. An investigation revealed that Employee 8, an LPN, received and signed for the delivery and placed the medications in the medication room, informing Employee 11, another LPN, of their location. However, the medications were left unattended, and Employee 11 did not recall handling the Tramadol. Video footage showed Employee 11 leaving the narcotic drawer open and unsecured while stepping away from the medication cart. Despite the controlled substance shift-to-shift count sheets confirming medications were accounted for, discrepancies were noted after the pharmacy alerted the facility of the missing medications. The facility's investigation did not include written witness statements from Employees 8 or 11, nor from other nursing staff assigned to the medication cart during the relevant period. Although Resident 16 did not miss any doses due to an existing supply, the misappropriation of medication was confirmed, and the investigation failed to identify the perpetrator responsible for the missing controlled substances.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the Tramadol was not found and the perpetrator not identified. The delivery of all narcotic medications will be checked and co-signed by the RN Supervisor/licensed designee and the LPN Charge Nurse assigned to the resident(s). If the LPN Charge Nurse is unavailable, another LPN can co-sign the narcotics. A copy of the narcotic(s) sheet, from the pharmacy will be copied and placed in a binder for the Director of Nursing. The RN Supervisor/licensed designee and LPN assigned to the resident(s) will place the narcotic in the appropriate medication cart(s) and the narcotic sheet(s) in the narcotic binder(s) located on the medication carts. The RN Supervisor and LPN co-sign placement of the narcotic in the locked box in the medication cart and on the Narcotic Medication Sheet. Educate employees on diversion awareness and recognizing indicators of impairment and diversion activity. The education program will be discipline specific and done on new employee orientation and annual mandatory education. Training will be conducted in a classroom setting and online learning modules. All incident reports will be reviewed by the Risk Team to ensure no other evidence of noncompliance of lift usage and/or abuse has occurred. The results of the random audit checks and investigation of incident reports will be presented to QAPI monthly x 12 months. The weekly Risk Management Committee will include narcotic oversight and will be responsible for developing and maintaining policies to prevent and respond to potential drug diversion while ensuring system standardization in practice, detection, security, and investigation related to controlled substances. The pharmacy will audit the Omnicell, secure dispensing cabinet and a camera above the Omnicell will be installed to identify staff members, verify opioid counting, identify a theft, and establish a time frame for investigation. The pharmacy will utilize monthly user reports to provide a list of users, wasting, overrides, and the number of controlled substances pulled. The pharmacy will notify the Director of Nursing and the Administrator of any trends or errors and report findings monthly in QAPI x 12 months. A list of all residents on narcotics will be compiled and a random audit of five residents per week will be audited for individual narcotic log maintenance and accurate narcotic counts. Weekly, a random medication cart will be inspected checking each drawer and compartment to ensure all medications are properly stored, labeled, within their expiration dates, and the cart is clean, functional, and secure, including the locking mechanism. The results of the random narcotic count audits, medication cart inspections, and narcotic sheets will be a Performance Improvement Project for Nursing and presented at QAPI monthly x 12 months.
Failure to Prevent UTIs in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. Resident 65, who was admitted with a urinary tract infection and benign prostatic hyperplasia, required the use of an indwelling catheter. The facility did not document the use of a leg bag for urinary drainage during daytime hours in the resident's care plan, despite it being part of the resident's routine care. This lack of documentation indicates a failure to individualize care to meet the resident's specific needs. Additionally, during an observation, the resident's urinary drainage bag was improperly stored inside a clear garbage bag tied to the railing beside the toilet, next to another resident's drainage bag, posing a risk for cross-contamination. The Director of Nursing confirmed that the urinary drainage bags were not being cleaned or stored according to infection control guidelines, and the facility could not provide evidence of staff education on the care and maintenance of urinary drainage systems. Furthermore, the facility lacked a policy or procedure outlining infection control practices specific to urinary catheters and drainage systems.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the resident has expired. Establish a list of residents who have bedside urinary drainage bags and convert to leg bags during the daytime hours. Review the resident list to ensure their individual care plans are up-to-date. Revision of Intermittent Use of Urinary Leg Drainage Bags to include protocol for conversion to leg bag, aftercare, and storage of bedside urinary collection bags. Staff will be educated on the proper protocol for urinary leg bag conversion, emptying, cleaning, and storage of the bedside urinary drainage bag. Develop an audit tool to monitor the residents who utilize leg drainage bags to ensure their care plans are up-to-date, and audit proper disposal, cleaning, and placement of the bedside drainage bag daily. An audit of residents with indwelling Foley Catheter devices with leg bag conversions will be conducted daily, five x per week, x 3 months and results present to QAPI monthly x3.
Failure in Pain Management Protocols
Penalty
Summary
The facility failed to provide effective pain management for a resident, as evidenced by the administration of pain medication without attempting non-pharmacological interventions first. The facility's policy on pain management, which was reviewed, requires the development and implementation of both non-pharmacological and pharmacological interventions tailored to the resident's needs. However, the facility did not adhere to this policy for one resident, who was administered pain medication without documented attempts of non-pharmacological interventions. The resident in question, admitted with multiple diagnoses including cerebral palsy, dysphagia, and contractures, had a comprehensive person-centered care plan that included goals for adequate pain relief. Despite this, the facility's records showed repeated instances where pain medication was administered without prior non-pharmacological interventions. This occurred multiple times over a period from January to February 2025, with pain levels documented as moderate to severe. Interviews with the Director of Nursing confirmed the lack of adherence to physician's orders and the absence of documented non-pharmacological interventions. The facility's failure to follow its own pain management policy and physician's orders resulted in a deficiency in providing appropriate care for the resident's pain management needs.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Identify and care plan nonpharmacological interventions for the resident's current pain management strategy. Using an interdisciplinary approach, review residents who currently receive pain medications, scheduled or as needed. Implement nonpharmacological interventions, relaxation techniques, back rub, lights, toilet, food/drink, and reposition. Education for all nursing staff to improve the quality of pain management to ensure resident outcomes enhance safety, physical and emotional functioning, and quality of life. In the development of a resident's individualized plan of care for pain management, consider a multidisciplinary approach, therapeutic, nonpharmacological interventions, and medication management. Educate clinical staff on the use of strategies for the management of pain including developing and implementing both nonpharmacological and pharmacological interventions to pain management. The Interdisciplinary Care Team will conduct five random audits weekly to review the clinical practice of pain management, including the application of nonpharmacological interventions and assessment of decrease in pain intensity, improved functional mobility, and reduction in pain-related distress. The audits will be reviewed weekly in the Risk Meeting and present monthly x3 in QAPI.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of a facility-initiated hospital transfer to a resident and their representative, which is a requirement under §483.15(c)(3)-(6)(8). This deficiency was identified during a review of clinical records and facility-initiated transfer notices, as well as through staff interviews. Specifically, the deficiency involved Resident 46, who was admitted to the facility with diagnoses including atrial fibrillation, heart disease, and a fracture of the left radius and ulna styloid process. The resident was transferred to the hospital on January 6, 2025, and readmitted to the facility on January 12, 2025. Upon reviewing the clinical record, it was found that there was no documented evidence that the facility provided the resident and their responsible party with a written notice of the transfer and the reason for it. This was confirmed in an interview with the Administrator, who acknowledged the lack of documentation indicating that the resident's responsible party was informed in writing about the transfer. This failure to provide the required notice constitutes a violation of the regulatory requirements for transfer and discharge notifications.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Deficient practice cannot be corrected as the missing transfer form cannot be located or replaced. Re-educate the nursing staff on completion of the Transfer/Discharge Form. The Business Office Manager/designee will create a spreadsheet to monitor the receipt of all Transfer/Discharge Forms compared to the Daily Census. The Business Office Manager/designee will report results of the audit to QAPI monthly x 3 months.
Failure to Report Influenza A Cases
Penalty
Summary
The facility failed to report cases of Influenza A to the appropriate health agencies and the Division of Nursing Care Facilities field office for 13 residents who tested positive. The infection control documentation revealed that residents tested positive for Influenza A on various dates from December 27, 2024, to January 18, 2025. An interview with the facility's Infection Control Practitioner and the Director of Nursing confirmed that the mandated state agencies were not notified of these positive cases, indicating a lapse in the facility's reporting protocol for reportable diseases.
Plan Of Correction
Preparation and/or constitution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The Administrator corrected the deficiency by reporting the influenza cases to the DOH on 12/27/24 at 0800, Event Number: 1066952. The Infection Control Nurse, Director of Nursing, Administrator, and Assistant Administrator reviewed and were educated on the PA regulations regarding ERS reporting requirements. § 27.21a. Reporting of cases by health care practitioners and health care facilities. (2) Influenza is reportable within 5 working days after being identified by symptoms, appearance, or diagnosis. Examination of the prior 24-hour clinical report and the daily Interdisciplinary Clinical Team Meeting will discuss any residents who exhibit signs of influenza, e.g., fever, chills, cough, sore throat, rhinorrhea, muscle/body aches, headaches, fatigue, vomiting, or diarrhea, and the need for diagnostic testing. If diagnosis is confirmed, treatment, isolation, and state reporting within 5 working days will be completed. Facility follows the Infection Control Guidance set for by the Centers for Disease Control and Prevention. The Infection Control Nurse has created a log of any reportable diseases, infections, and conditions. An additional checkbox will be added to the Infection Preventionist's Infection Control Log to indicate any reportable diseases have been or need to be submitted to the Department of Health. Infection Control and Nursing Administration reviewed all cases; there were no additional reportable events required. The Infection Preventionist will report monthly x three months to QAPI to ensure regulatory compliance in reporting infectious diseases has been met. The Infection Preventionist's log will be reviewed by QAPI team and the Administrator to ensure reporting requirements have been met.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in psychosocial harm. The incident involved a resident who was moderately cognitively impaired, with a BIMS score of 7, and had medical conditions including atherosclerotic heart disease and diabetes. The resident reported to a nurse aide that a man entered her room during the night, pinned her down, and sexually assaulted her. The resident was found with her pajama bottoms at her knees and expressed pain and fear, refusing a physical assessment at the facility. The facility's investigation revealed that the resident was taken to the hospital for a SANE examination, which documented abrasions, lacerations, and bruising consistent with sexual assault. The facility's deployment sheet indicated that there was one male agency nurse aide on duty during the shift when the incident occurred. The resident's statement and subsequent interviews confirmed the assault, although the resident could not describe the assailant due to the darkness in the room. The facility's documentation and witness statements from staff members did not provide a clear account of the events during the night shift. The Director of Nursing confirmed the occurrence of the sexual assault and the resulting psychosocial harm to the resident. The facility's failure to protect the resident from abuse was a significant deficiency, as outlined by the relevant Pennsylvania Code sections.
Failure to Provide Abuse Prevention Training to Agency Staff
Penalty
Summary
The facility failed to provide abuse prevention training to agency nursing staff, specifically for two employees, Employee 3 and Employee 8. Employee 3, an agency nurse aide, began working at the facility on November 13, 2023, and has been working steadily since then. Employee 8, an agency registered nurse, stated during an interview on August 5, 2024, that he had been working at the facility for three months without receiving training on the facility's abuse prohibition policy. There was no documentation to confirm that Employee 8 was trained on the facility's abuse prohibition policies and procedures as part of staff orientation. The facility staffing coordinator confirmed that while she verifies agency staff credentials, such as background checks and nursing licenses, she does not request any abuse training. The facility relies on agency staff to maintain adequate staffing ratios but could not provide evidence of abuse training for any agency staff currently working at the facility. The Director of Nurses confirmed that agency staff are not trained on the facility's policy and procedures as part of staff orientation before assuming their duties.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to submit a timely and thorough investigation of an alleged sexual abuse incident involving a resident. The resident, who was moderately cognitively impaired, reported to a nurse aide that a man had entered her room during the night and sexually assaulted her. The nurse aide and an LPN reported the incident to the Director of Nursing (DON), who attempted a physical assessment, but the resident was too distressed to proceed. The resident was then sent to the hospital for evaluation, and relevant authorities were notified. However, the facility did not conduct interviews with all staff on duty during the alleged incident, and there was no documented evidence of a completed investigation in the resident's clinical record. The DON confirmed that the facility had not conducted a thorough investigation into the incident, despite the resident's allegations and symptoms. There was no documented evidence of a completed abuse investigation or corrective actions taken to prevent further potential abuse. The lack of documentation and follow-up was confirmed during an interview with the DON, indicating a failure to adhere to the facility's policy on abuse prevention and investigation.
Failure to Update Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan to address the aggressive behaviors of a resident diagnosed with dementia with behavioral disturbance. The resident, who was severely cognitively impaired with a BIMS score of 3, required assistance for activities of daily living. Despite these needs, the resident's care plan, initially dated July 4, 2023, did not include any reference to her physically aggressive behaviors. This oversight was highlighted following an incident on July 26, 2024, when the resident exhibited aggressive behavior during an outing with her son, resulting in physical altercations and injuries. The incident report revealed that the resident's son, who had not seen his mother in a while, was unprepared to manage her aggressive behavior. Upon returning to the facility, the son reported that the resident had become violent, leading to a physical confrontation. The nursing staff documented bruising and a skin tear on the resident, who had no recollection of the event. The Director of Nursing confirmed that the resident's aggressive behaviors were not addressed in her care plan, and there was no evidence that the son had been informed or educated about these behaviors prior to the outing.
Incomplete Documentation of Resident Incident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was moderately cognitively impaired and had a history of atherosclerotic heart disease and diabetes. During a quarterly Minimum Data Set assessment, the resident was found to have a BIMS score of 7, indicating moderate cognitive impairment. An incident occurred where the resident reported to a nurse aide that a man had entered her room during the night and sexually assaulted her. The nurse aide reported this to an LPN, and both informed the Director of Nursing (DON). Attempts to conduct a physical assessment were unsuccessful as the resident became distressed and refused to undress. The resident's brief, which was soaked with urine, was preserved as evidence, and the State Police, Physician, responsible party, and Department of Aging were notified. The resident was subsequently taken to the hospital for evaluation. The deficiency was identified during a review of the resident's clinical records and staff interviews, which revealed that the facility did not document the incident comprehensively. The DON confirmed that the clinical record lacked complete and accurate documentation regarding the incident. The absence of detailed documentation in the resident's clinical record was a significant oversight, as it failed to provide a full account of the events and actions taken following the reported incident. This lack of documentation was a violation of accepted professional standards for maintaining medical records.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged abuse incident involving a resident with dementia, depression, and muscle weakness, who was severely cognitively impaired and used a wheelchair for mobility. On May 16, 2024, a nurse aide, identified as Employee 1, was reported to have held the resident by the back of their sweater and screamed at them. Despite being escorted out of the building, Employee 1 was later allowed to return to duty. The incident was witnessed by other staff members, who provided statements describing the resident's distress and Employee 1's actions, including pulling the resident by their sweater and wheelchair down the hallway. The facility's policy required that allegations of abuse be reported to the State Survey Agency within 24 hours, but this was not done until May 28, 2024, after surveyor inquiry. The nursing home administrator and director of nursing confirmed the incident and the failure to report it in a timely manner. The facility's policy also required immediate notification of the Area Agency on Aging and local law enforcement in cases of abuse, but there was no documented evidence that these steps were taken promptly. The deficiency was identified as a failure to adhere to the facility's abuse prevention and reporting procedures.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to promptly conduct a thorough investigation and report an alleged abuse incident involving a resident to the State Survey Agency within the required timeframe. The incident involved a nurse aide, Employee 1, who was reported to have physically and verbally abused a resident with dementia, depression, and muscle weakness. The resident was severely cognitively impaired and used a wheelchair for mobility. On the day of the incident, Employee 1 was seen holding the resident by the back of her sweater and screaming at her, which led to the resident crying and expressing distress. Despite the severity of the allegations, the facility did not follow its own abuse prevention policy, which mandates immediate investigation and reporting of such incidents. Although Employee 1 was initially removed from the building, she was later allowed to return to duty without a completed investigation. The facility obtained statements from staff on the day of the incident but failed to report the alleged abuse to the State Survey Agency within the required five working days. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to provide evidence of a timely and complete investigation. The facility did not submit the results of the investigation to the State Survey Agency as required, violating several state codes related to the responsibility of the licensee, management, and resident rights.
Failure to Implement Restorative Nursing Program and Apply Ankle Support
Penalty
Summary
The facility failed to provide restorative nursing services and devices to maintain mobility and range of motion for Resident 34. The resident, who was admitted with diagnoses including difficulty in walking, abnormal posture, osteoarthritis, and muscle weakness, was discharged from physical therapy with recommendations for a restorative nursing program (RNP). However, there was no documented evidence that an RNP was developed or implemented. Additionally, the resident had a physician's order for an ankle stirrup to be applied when out of bed, but observations revealed that the device was not being used as required. Interviews with the resident and staff confirmed that the ankle support was not being applied, and the resident expressed concerns about the lack of an RNP and the potential impact on her mobility. Further observations and interviews confirmed that the facility did not follow through with the physical therapy recommendations or the physician's order for the ankle stirrup. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) acknowledged that the RNP was not implemented and that the support device was not being applied by staff. The Director of Therapy also confirmed that the resident was supposed to use the ankle support device for stability during ambulation and transfers, but this was not being done. The facility's failure to provide the necessary restorative nursing services and devices resulted in a deficiency in maintaining the resident's level of function.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to maintain infection control practices to prevent the spread of infection for three residents. Resident 75, who had a urinary tract infection and multiple pressure ulcers, was observed without Enhanced Barrier Precautions (EBP) for his pressure ulcer and indwelling catheter. Despite a physician's order for an indwelling catheter and subsequent complications, including septic shock and a urinary tract infection caused by Serratia marcescens, the facility did not implement the necessary infection control measures. Resident 70, diagnosed with diabetes mellitus and urinary retention, also had an indwelling catheter and a left gluteal fold abrasion. Observations revealed an opened bottle of normal saline solution on the resident's dresser without a date or time of opening, contrary to facility policy. There was no evidence that EBP was implemented for the resident's wound and indwelling catheter, as required. Resident 24, with diagnoses including Guillain Barre Syndrome, chronic stage 4 pressure ulcers, a suprapubic indwelling catheter, and a colostomy, was also not provided with EBP. Multiple observations confirmed the absence of EBP for the resident, despite the need due to the presence of external devices and chronic conditions. The Director of Nursing and the Nursing Home Administrator confirmed the facility's failure to identify and implement the necessary precautions for these residents.
Failure to Notify Resident's Representative of Significant Weight Loss
Penalty
Summary
The facility failed to timely notify the resident's interested representative of a significant weight loss for Resident 26. Resident 26, who was admitted with a diagnosis of Parkinson's disease, experienced a weight decrease from 149 lbs on June 3, 2023, to 130.2 lbs on December 3, 2023, amounting to a 12.4% loss of body weight over six months. Although the resident's attending physician was informed of the weight loss on December 20, 2023, there was no documented evidence that the resident's representative was notified. This deficiency was confirmed during an interview with the Nursing Home Administrator on April 4, 2024.
Failure to Address Significant Weight Loss in Care Plan
Penalty
Summary
The facility failed to address a significant weight loss in a resident's comprehensive care plan. Resident 26, who was admitted with a diagnosis of Parkinson's disease, experienced a weight loss from 149 lbs to 130.2 lbs over six months, a 12.4% decrease in body weight. Despite this significant weight loss, the resident's care plan did not include any measures to address the decline in nutritional status. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged that the care plan did not address the resident's weight loss and nutritional needs.
Failure to Timely Identify and Treat Pressure Sores
Penalty
Summary
The facility failed to timely identify, assess, and treat a pressure sore for Resident 24. The resident, who had a history of hypertension, type II diabetes, and congestive heart failure, was found to have an open area on the right buttock. Despite the discovery, there was no documented evidence that a thorough assessment was completed by a registered nurse (RN) or that timely treatment orders were obtained and implemented. The facility also lacked documentation of consistent monitoring and wound tracking for the resident's pressure sore, as confirmed by the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA). For Resident 13, who had a history of a left hip fracture and dementia, the facility failed to consistently monitor skin integrity related to the use of a knee immobilizer. The resident was admitted with a left knee immobilizer and was at moderate risk for skin breakdown. Despite this, there was no evidence that the facility monitored the resident's skin during the application and removal of the immobilizer. This oversight led to the development of a pressure wound on the left calf, which was later identified and treated by a wound care physician. The deficiencies were confirmed through clinical record reviews, staff interviews, and observations. The facility was unable to provide documented evidence of timely and thorough assessments, consistent monitoring, and appropriate treatment for the pressure sores of both residents. These failures were acknowledged by the ADON and the Director of Nursing during the survey.
Failure to Administer and Maintain Oxygen Therapy
Penalty
Summary
The facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for Resident 85. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypoxia, had a physician's order for continuous oxygen therapy at three liters per minute via nasal cannula. Facility policy required that the oxygen setup, including the nasal cannula and humidifier, be changed and dated weekly. However, observations on multiple occasions revealed that the nasal cannula tubing was not dated according to facility policy, and the resident was not receiving oxygen as ordered. Specifically, on one occasion, the nasal cannula was found under three blankets on the bed next to the resident, who was seated in a wheelchair without the nasal cannula on, despite the oxygen concentrator being turned on. Interviews with the Certified Nurse Aide (CNA), Director of Nursing (DON), and Nursing Home Administrator (NHA) confirmed that the physician's order for supplemental oxygen was not followed for Resident 85 and that the oxygen equipment was not maintained as per the facility's policy. The facility's failure to adhere to the prescribed oxygen therapy and maintain sanitary oxygen delivery systems was in violation of the facility's own policies and state regulations, specifically 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services and 28 Pa. Code 211.10 (a)(c)(d) Resident care policies.
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 236 citations issued within 25 miles in the last 12 months — including the 3 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 Waymart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carbondale Rehabilitation And Healthcare Center | 5.2 mi | ★★★★★ | 5 | 0 |
| Aventura At Creekside | 5.5 mi | ★★★★★ | 16 | 1 |
| Forest City Nursing And Rehab Center | 6 mi | ★★★★★ | 0 | 0 |
| Ellen Memorial Rehabilitation And Healthcare Cente | 6.4 mi | ★★★★★ | 4 | 0 |
| Julia Ribaudo Extended Care Center | 9.1 mi | ★★★★★ | 29 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.