Above 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 Healthcare Center during CMS and state inspections, most recent first.
Call lights were not kept within reach for multiple residents. One resident was observed trying to reach a call bell on the floor while nearly rolling out of bed, another was heard calling for help with the call bell clipped out of reach at the head of the bed, and a resident with stroke-related left-sided weakness could not reach the call light placed on the left side.
Food service failed to provide palatable, attractive meals at an appetizing temperature. During meal observation, residents and staff reported overcooked, brown, mushy cauliflower, and one resident on a puree diet received the wrong entrée while others did not receive ordered double portions or a prescribed supplement. A cook confirmed a prepared puree item was missed during service.
Infection prevention and control was deficient when surveyors observed a wheelchair with holes in the seat exposing inner padding and a Geri-Chair with rips and tears exposing inner padding. The Infection Preventionist and B Hall Nurse manager confirmed the damaged equipment during the walk-through.
The facility failed to store and serve food in accordance with professional standards by keeping chocolate milk beyond its expiration date and by not ensuring all staff were wearing hairnets. A gallon of chocolate milk with an expiration date of 04/26/24 was found in the refrigerator, and an employee was observed washing dishes without a hairnet. These deficiencies were confirmed by the Dietary Corporate Manager and had the potential to affect all 60 residents.
The facility failed to maintain a clean environment by leaving an uncovered bedpan on the bathroom floor in room A13, observed on three separate occasions. Additionally, the facility did not follow its policy to test for Legionellosis annually, with the last test recorded on 09/14/22.
The facility failed to ensure the Daily Staffing Posting information was accurate and current, with discrepancies in direct care hours and incorrect inclusion of administrative staff hours as direct care. The Administrator acknowledged these inaccuracies during the survey process.
The facility failed to provide chairs in residents' rooms, leading to a resident's brother sitting on a PTAC unit due to the absence of seating. The Administrator acknowledged the issue and stated that many rooms lacked chairs, which would be replaced to ensure a functional and comfortable environment.
The facility failed to ensure a resident was treated with dignity and respect, as the resident was observed with long chin hairs that she wanted removed. The DON acknowledged the issue and stated it would be addressed immediately.
The facility failed to inform a resident or their representative about the risks and benefits of an antipsychotic medication before its administration. The Director of Nursing confirmed that the necessary education was not provided prior to starting the medication.
The facility failed to issue a beneficiary notification within the appropriate time frames for a resident. The last covered day of Medicare services was 12/14/23, but the Notice of Medicare Non-Coverage (NOMNC) was issued on the same day, making the appeal process inaccessible. This deficiency was confirmed during an interview with the Nursing Home Administrator.
The facility failed to maintain a sanitary and homelike environment, with issues including a soiled turn and positioning device, holes in the wall, and a dirty bathroom. Staff were unaware of cleaning requirements, and the Administrator confirmed the deficiencies.
The facility failed to protect a resident from abuse when another resident hit her in the eye, and another resident from inappropriate language used by a CNA. Both incidents resulted in actual harm to the residents involved.
The facility failed to accurately encode the MDS for a resident upon discharge, marking it as unplanned despite evidence of a planned discharge. This error was confirmed through staff interviews and a review of the resident's medical records.
The facility failed to update PASARR forms to reflect new mental health diagnoses for three residents. One resident had multiple new diagnoses, including Schizoaffective disorder and Major Depressive Disorder, none of which were updated in the PASARR. Another resident was diagnosed with Bipolar Disorder, but the PASARR was not updated. A third resident's PASARR did not reflect a new diagnosis of Major Depressive Disorder. The DON confirmed these oversights during interviews.
The facility failed to ensure that the PASARR reflected the admitting diagnoses for two residents. One resident's PASARR did not include Schizoaffective disorder, and another's did not include Bipolar Disorder and Mild Cognitive Impairment. These discrepancies were confirmed by the DON.
The facility failed to develop and implement an individualized comprehensive care plan for a resident diagnosed with urinary incontinence. Despite an assessment indicating the need for a toileting program, the resident's care plan did not address this diagnosis. The DON acknowledged this oversight.
A resident with a BIMS score of 8 reported a foot injury caused by a fallen walker. Despite informing a nurse, no further action was taken. Observation revealed significant bruising, and staff interviews confirmed the lack of medical treatment or documentation. The ADON acknowledged the need for an x-ray after observing the injury.
Call Lights Not Within Reach
Penalty
Summary
The facility failed to ensure resident call lights were within reach and failed to ensure residents did not have long waits for call lights to be answered. Resident #21 was observed lying in bed trying to reach her call bell, which was on the floor beside her bed, and she was almost rolling out of bed while attempting to reach it. Resident #27 was heard calling for help and was observed sitting in her wheelchair near the foot of her bed with her call bell clipped to her pillow at the head of the bed and out of reach; the RN confirmed the call light was not within reach and assisted the resident back into bed. Resident #6, who had a stroke with left-sided weakness, had the call light placed on her left side during enteral tube care, and when asked to activate it, she could not reach across her body to use it; this was confirmed by the RN.
Unappetizing Meal Service and Missed Ordered Items
Penalty
Summary
Food and drink were not consistently prepared and served in a palatable, attractive manner at a safe and appetizing temperature. During dining observations, multiple residents reported that the vegetables were mushy, brown, or otherwise unappetizing, and staff and the district manager confirmed the cauliflower was overcooked. One resident stated the vegetables would be better if they were not mushy, another said the cauliflower was too mushy and brown, and a feeding assistant/activity director said she would not touch the cauliflower because it was too discolored. Other residents also described the cauliflower as brown mush and said the vegetables were cooked "to death" and sometimes could not be identified. The meal service also did not match ordered diets and portions for several residents. One resident on a double-portion diet did not receive double portions of lasagna or cauliflower, another resident on a dysphagia puree diet was served puree lasagna instead of the ordered puree breaded chicken patty, and a resident did not receive the ordered magic cup with lunch. The cook verified the puree chicken had been prepared but was not served, stating it was missed. These findings involved multiple residents during the same meal observation and were documented through resident interviews, staff interview, and review of the production sheet and diet slips.
Infection Control Deficiency Involving Damaged Wheelchair and Geri-Chair
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to resident personal products and unsanitary practices. During a facility walk-through, surveyors observed one wheelchair in the A hallway with holes in the seat exposing the inner padding near the front left screw, and one Geri-Chair outside the Central Shower Room with rips and tears down both sides of the back rest and on the right armrest, exposing the inner padding. During an interview and walk-through with the Infection Preventionist, the B Hall Nurse manager was present and confirmed that the wheelchair and Geri-Chair had tears and holes exposing inner padding.
Expired Chocolate Milk and Lack of Hairnets in Kitchen
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards by keeping chocolate milk beyond its expiration date and by not ensuring all staff were wearing hairnets. During an initial tour of the kitchen, a gallon of chocolate milk with an expiration date of 04/26/24 was found in the reach-in refrigerator on 04/29/24. Additionally, an employee was observed washing and putting up dishes without wearing a hairnet. These deficiencies were confirmed by the Dietary Corporate Manager and had the potential to affect all residents currently residing in the facility, which had a census of 60 residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure a clean, sanitary environment by leaving an uncovered bedpan on the bathroom floor in room A13. This was observed on three separate occasions: at 11:28 AM and 1:17 PM on 04/29/24, and again at 9:00 AM on 04/30/24, with the facility Administrator confirming the bedpan's presence. Additionally, the facility did not follow its policy to test for Legionellosis annually. The last recorded test was on 09/14/22, as confirmed by a review of the facility's Water Management/Legionella Plan and an interview with the Administrator on 05/01/24.
Inaccurate Daily Staffing Posting Information
Penalty
Summary
The facility failed to ensure the Daily Staffing Posting information was accurate and current with the actual direct care hours and the identified direct care staff. This deficiency was observed in four out of five Daily Staffing Posting forms reviewed during the long-term care survey process. Specifically, the posted direct care hours on 04/04/24, 04/05/24, 04/12/24, and 04/18/24 were found to be inaccurate when compared to the Actual Hours for Direct Care Staff Report. The discrepancies ranged from 2.75 to 28.5 hours. The Administrator acknowledged these inaccuracies during an interview on 05/01/24, agreeing that the posted hours were more than the actual reported hours worked. Additionally, the facility inaccurately included the hours of the Registered Nurse Director of Nursing (RN DON) and Registered Nurses (RNs) with administrative duties as direct care hours on the Daily Staffing Posting forms for the same dates. The Administrator explained that these hours were included because the RN DON and RNs with administrative duties sometimes assist with daily care. However, according to the Centers for Medicare & Medicaid Services (CMS) guidelines, the hours should be reported based on the employee's primary role. The Administrator acknowledged that the RN DON hours and the RNs with administrative duties hours should not have been included as direct care hours on the Daily Staffing Posting forms.
Lack of Chairs in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility did not provide chairs in residents' rooms for use by residents and visitors. During an interview with a resident, it was observed that the resident's brother was sitting halfway on the room's packaged terminal air conditioner (PTAC) unit due to the absence of a chair. The resident's brother mentioned that the room never had a chair, and he sometimes had to find a fold-up chair if available. The Administrator acknowledged that many rooms lacked chairs and stated that he would replace them, recognizing the need for a functional and comfortable homelike environment.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect. During an observation, the resident was noted to have long chin hairs that needed removal. In an interview, the resident confirmed she did not like having chin hair and wanted it removed. The Director of Nursing, present during the interview, agreed that the chin hair needed to be removed and stated she would address it immediately.
Failure to Inform Resident of Antipsychotic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform the resident or the resident's representative about the risks and benefits of an antipsychotic medication before its administration. This deficiency was identified during a review of the medical record for Resident #36, who was receiving Risperidone, an antipsychotic medication ordered on 03/07/24. The review revealed no documentation indicating that education regarding the risks and benefits of the medication was provided to the resident's healthcare decision maker prior to starting the medication. The Director of Nursing confirmed that this educational step was not completed before the medication was administered.
Failure to Issue Timely Beneficiary Notification
Penalty
Summary
The facility failed to issue a beneficiary notification within the appropriate time frames for one of three residents reviewed during the long-term care survey process. Specifically, for Resident #111, the last covered day of Medicare services was 12/14/23, but the Notice of Medicare Non-Coverage (NOMNC) was issued to the responsible party on the same day, 12/14/23. The form indicated that the appeal needed to be filed by 12/13/23, which was one day before the responsible party was notified, making the appeal process inaccessible. This deficiency was confirmed during an interview with the Nursing Home Administrator on 05/01/24.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable homelike environment for its residents. During a tour of the facility, room [ROOM NUMBER]A was found to have a soiled turn and positioning device in the bathroom. Licensed Practical Nurses (LPNs) #45 and #65 were unaware of the cleaning requirements for this equipment. The Administrator confirmed that the equipment was not properly cleaned and sanitary for resident use, as per the facility's infection control policies and standard procedures for maintenance and repair of equipment used for resident care. In room A14-B, two holes were observed in the wall behind the B bed, which were left from a previously replaced overhead light. The Administrator confirmed the issue and stated that the holes would be fixed as soon as possible. Additionally, the bathroom in room B14 was observed to have a brown substance smeared on the floor by the toilet on two separate occasions. The Director of Plant Maintenance confirmed that the floor needed cleaning and indicated that the room should be cleaned daily.
Failure to Protect Residents from Abuse and Inappropriate Language
Penalty
Summary
The facility failed to ensure Resident #30 was free from abuse, resulting in an incident where Resident #57 hit Resident #30 in the left eye. This incident was witnessed by the Activities Director and two guests. Resident #30, who has multiple diagnoses including Alzheimer's disease, dementia, and chronic kidney disease, was unable to indicate how the incident affected her due to her cognitive impairment. The facility's records show that the incident was reported to the physician and appropriate state agencies, and an investigation was initiated immediately. Resident #57, who has a history of epilepsy, anoxic brain damage, and other medical conditions, was placed on one-on-one supervision and later discharged from the facility. The facility conducted head-to-toe assessments and pain assessments for Resident #30, which documented no physical injuries or signs of pain following the incident. However, the reasonable person standard was applied, indicating that a reasonable person would suffer psychosocial harm from being hit by another resident, thus constituting actual harm for Resident #30. The facility also failed to ensure Resident #16 was free from inappropriate language from a staff member. Resident #16 reported hearing a CNA use profanity and express reluctance to care for her. The incident was reported to the facility's administration, and an investigation was conducted. Multiple staff members corroborated Resident #16's account, confirming that the CNA did use profanity in front of the resident. The CNA was placed on unpaid suspension and later resigned during the investigation. Resident #16, who has a history of being upset by the CNA's behavior, expressed that she no longer wanted the CNA to care for her. The facility's records show that the CNA had completed training on elder abuse and preventing, recognizing, and reporting abuse prior to the incident. Both incidents highlight the facility's failure to protect residents from abuse and inappropriate behavior, resulting in actual harm to the residents involved. The facility's immediate actions to address the incidents and prevent recurrence were noted, but the deficiencies were cited as past non-compliance due to the harm caused to the residents.
Failure to Accurately Encode MDS Upon Discharge
Penalty
Summary
The facility failed to accurately encode the Minimum Data Set (MDS) for a resident upon discharge. During a medical record review, it was found that there were no notes for the anticipated discharge of a resident prior to the discharge date. The discharge summary was completed by all required departments and included necessary follow-up information. However, the MDS was incorrectly marked as an unplanned discharge, despite evidence indicating that the discharge was planned. This discrepancy was confirmed through staff interviews, including the Unit Manager LPN and the Regional Director of Finance, who clarified that there were no financial reasons for the early discharge and that the resident had won an appeal regarding their Medicare coverage. The Administrator acknowledged that the discharge was planned and that the MDS was not encoded correctly. The error was attributed to the resident's son coming to get the resident one day before the originally planned discharge date, which led to the incorrect marking of the discharge as unplanned. This failure to accurately encode the MDS upon discharge was identified during the long-term care survey process and affected one of the two resident discharges reviewed.
Failure to Update PASARR Forms for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) forms were updated to reflect new diagnoses for residents with newly diagnosed mental illnesses. This deficiency was identified for three out of four residents reviewed for the PASARR care area. Resident #26 had multiple new diagnoses, including Schizoaffective disorder, Major Depressive Disorder, Mild cognitive impairment, Delusional Disorder, Paranoid Personality Disorder, and a history of Bipolar Disorder, none of which were updated in the PASARR submitted on 03/01/23. The Director of Nursing confirmed that these new diagnoses were not submitted on a PASARR during an interview on 04/30/24. Similarly, Resident #41 was diagnosed with Bipolar Disorder on 09/15/20, but the PASARR was last completed on 08/28/20, and no new PASARR was submitted to reflect this change. The Director of Nursing acknowledged this oversight during an interview on 04/30/24. Additionally, Resident #52 was diagnosed with Major Depressive Disorder on 06/06/23, but the last PASARR completed on 01/20/23 did not include this diagnosis. The Director of Nursing confirmed that a new PASARR had not been completed for Resident #52 during an interview on 05/01/24. These failures indicate a systemic issue in updating PASARR forms to reflect new mental health diagnoses promptly.
PASARR Screening Deficiency for Mental Disorders or Intellectual Disabilities
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) reflected the admitting diagnoses for two residents. For Resident #26, the medical record revealed an admitting diagnosis of Schizoaffective disorder on 09/08/22, but the PASARR submitted on 03/01/23 did not reflect this diagnosis. This discrepancy was confirmed by the Director of Nursing during an interview on 04/30/24. Similarly, for Resident #14, the medical record showed admitting diagnoses of Bipolar Disorder and Mild Cognitive Impairment of Uncertain or Unknown Etiology on 05/25/23, but the PASARR submitted on 05/23/23 by a local hospital did not include these diagnoses. This was also verified by the Director of Nursing during the same interview.
Failure to Develop and Implement Individualized Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan for a resident diagnosed with urinary incontinence. A record review revealed that the resident had a urinary incontinence assessment completed, indicating the need for a toileting program titled Check and Change. However, the resident's current care plan did not include any individualized comprehensive care plan for this diagnosis. During an interview, the Director of Nursing acknowledged that the resident had not been care planned for her urinary incontinence diagnosis as required.
Failure to Provide Timely Medical Treatment for Foot Injury
Penalty
Summary
The facility failed to provide timely medical treatment for a foot injury for one of the residents. Resident #52, who has a Brief Interview for Mental Status (BIMS) score of 8, reported that her walker fell on her foot, causing pain and bruising. Despite informing a nurse immediately after the incident, no further action was taken to address the injury. An observation revealed dark purple and red bruising on her right big toe and the adjacent toe, extending down the side and top of her foot. Interviews with staff confirmed that no medical treatment or documentation had been provided for the injury, and the Assistant Director of Nursing acknowledged the need for an x-ray after observing the resident's foot.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Center | 11.3 mi | ★★★★★ | 32 | 0 |
| Huntington Health And Rehabilitation Center | 11.8 mi | ★★★★★ | 19 | 0 |
| Madison Park Healthcare | 12.1 mi | ★★★★★ | 4 | 0 |
| Riverview Post Acute | 12.6 mi | ★★★★★ | 5 | 0 |
| St. Mary's Hospital | 13.5 mi | ★★★★★ | 2 | 0 |
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