Wayne Center for Nursing & Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the resident and their representative were provided with a copy of the resident health care records upon written request and two working days' advance notice to the facility. This was evident for one of two residents (Resident #15) reviewed for Choices and one of two residents (Resident #117) reviewed for Notification of Change out of 38 sampled residents. Specifically, 1) Resident #15 requested medical records on 05/25/2026, which were not received until 06/09/2026, and 2) Resident #117's representative requested medical records on 05/29/2026, which were not received until 06/15/2026.

Inspectors wroteNumber of residents sampled: 2Number of residents cited:1Based on record reviews and interviews, the facility failed to make prompt efforts to resolve grievances. This was evident for one resident (Resident #131) of two residents reviewed for Personal Property. Specifically, facility failed to investigate and provide a written grievance decision to Resident #131's representative regarding missing personal items.

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1 Based on observation, record review, and interview, the facility failed to ensure that the resident received adequate supervision to prevent accidents. This was evident for one resident (Resident #131) of four residents reviewed for accidents. Specifically, Certified Nursing Assistant #10 did not provide the necessary supervision to a severely confused resident who was also identified as restless, agitated, and at high risk for falls during an attempted transfer to bed. Certified Nursing Assistant #10 left Resident #131 alone in the room, and Resident #131 attempted to transfer independently and fell while trying to get into bed without assistance. Upon re-entering the room, Certified Nursing Assistant #10 placed Resident #131 back into bed without first notifying the nurse or obtaining an assessment by the nurse. [...]

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1 Based on observation, record review, and interviews, the facility failed to ensure medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident were provided. This was evident in one resident (Resident #131) of four residents reviewed for Discharge out of 38 sampled residents. Specifically, there was no documented evidence in the resident's medical record that appropriate information was communicated to the receiving facility when Resident #131's representative request a transfer to another facility.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 1/13 /2025 to 1/21/2025, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and pantry observations. Specifically, 1.) The dairy walk-in refrigerator contained opened and expired loaves of bread and bags of rolls. 2.) 2 of 6 pantry unit refrigerators contained expired milk as well as spilled, spoiled, undated and unlabeled food items.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that the garbage storage areas were maintained in sanitary condition. This was evident during the Kitchen Observation. Specifically, kitchen waste was not disposed of properly and the outside garbage compacter lid was left open and uncovered.

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that a comprehensive care plan was developed and implemented to meet each resident's needs. This was evident in 1 (Resident #46) out of 38 sampled residents. Specifically, Resident #46 who had diagnosis of Osteoporosis had no care plan developed and implemented.

Inspectors wroteBased on record reviews and interviews conducted during the Recertification Survey between 01/13/2025 and 01/21/2025, the facility did not ensure that resident's Comprehensive Care Plan was reviewed and revised by the interdisciplinary team after each assessment, including quarterly review assessments. 1) Resident #74 Self care Comprehensive Care Plan was last reviewed 8/1/2024, and not updated quarterly, 2) Resident #187 who was maintained on Oxygen Therapy the Alteration in Cardiopulmonary Care Plan was not updated. This was evident for 1 of 5 residents of reviewed for Activities of daily Living (Resident #74), and 1 out of 3 resident review for oxygen (Resident #187) out of an investigative sample of 37 residents.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 2 (Resident # 19 and #187) out of 6 residents reviewed for respiratory care out of 38 sampled residents. Specifically, 1) Resident # 19 was observed using oxygen via the Nasal Cannula (NC) at 2 liters with no Medical Doctor's Order (MDO), and 2) Resident # 187 was observed using oxygen via undated nasal cannula tubing.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that the Medical Director participated in the Quality Assurance and Performance Improvement quarterly meetings. This was evident during review of the attendance sheets for the last four quarterly meetings, and the facility provided list of members of the Quality Assurance and Performance Improvement Committee, and through interview with the Medical Director and other members of the Quality Assurance Committee. Specifically, the Medical Director stated that they do not attend the Quality Assurance quarterly meetings, and the Administrator stated that the Medical Director was too busy to attend the Quarterly Assurance quarterly meetings.

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/20245, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #187) of 35 total sampled residents. Specifically, Resident #187 did not receive monitoring and maintenance of the peripheral intravenous site for the infusion of fluids and antibiotics. The finding is: The facility's policy and procedure titled Administration, Monitoring and Maintenance of Intravenous Therapy, undated, documented that the facility shall have a system in place for the administration, monitoring and maintenance of Intravenous therapy. Intravenous tubings shall be labeled with the date and time change. [...]

Inspectors wroteBased on observation, record review interviews, and record review conducted during the recertification and complaints (NY00342658) survey from 01/13/2025 to 01/21/2025, the facility did not ensure a resident remained free of accident hazards. This was evident for 1 (Resident #290) of 3 residents reviewed for accidents out of 38 sampled residents. Specifically, Resident #290 fell out of bed and sustained a 2.5 cm skin tear to the forehead during care when one staff provided care without a second staff member.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 12/12/2022 to 12/19/2022, the facility did not ensure safe food storage and infection control was practiced. Specifically, (1) expired pancake and waffle syrup, gallon bottles of distilled vinegar, and teriyaki sauce were observed in the dry storage room and expired cottage cheese was observed in the refrigerator, and (2) staff did not perform hand hygiene after handling a cup that touched the floor and in between serving residents lunch trays. This was evident during the Kitchen Observation and Dining Task.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification survey from 12/12/22 to 12/19/22, the facility did not ensure each resident remained free from physical restraints. Specifically, there were no ongoing re-evaluation assessments conducted for the need for bilateral upper and lower side rails for Residents #58 and #112. The two residents were observed on several occasions in bed with bilateral upper and lower side rails in use. This was evident for 2 out of 7 residents reviewed for Physical restraints out of a sample of 39 residents.

Inspectors wroteBased on interview and record review conducted during a Recertification and Complaint survey (NY00303408) conducted from 12/12/22 to 12/19/2022, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, to the State Survey Agency. Specifically, the facility did not report an allegation of resident-to-resident abuse to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for two allegations for 2 of 2 residents reviewed for Abuse out of a sample of 39 residents. (Resident #49 and Resident #148)

Inspectors wroteBased on record review and staff interview conducted during a Recertification survey from 12/12/2022 to 12/19/2022, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, 1). the MDS did not accurately document falls for a resident with a history of falls, and 2). MDS assessments did not accurately document that four side rails were used with a resident. This was evident for 1 of 4 residents reviewed for Accidents and 2 of 7 residents reviewed for Physical Restraints out of a of 39 sample residents. (Resident #37, #112, and #58).

Inspectors wroteBased on the record review and interview conducted during a Recertification survey from 12/12/2022 to 12/19/2022, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in the review of their Comprehensive Care Plan (CCP). Specifically, resident and their representatives were not invited to participate in the review and revision of the residents' care plan. This was evident 2 of 4 residents reviewed for Care Planning out of 39 sampled residents. (Resident #112, and #37)

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 12/12/22 to 12/19/22, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 of 3 residents reviewed for Mobility out of 39 sampled residents (Resident #208). Specifically, there was no documented evidence that Resident #208 right knee orthosis was applied in accordance with a physician's order.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that a resident received services to prevent a further reduction in mobility. Specifically, a resident with an order for splinting devices to prevent worsening of contractures to bilateral upper extremities was observed on multiple occasions without splinting devices in place. This was evident for 1 of 2 residents reviewed in the areas of Position/Mobility (Resident #53).

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a resident's oxygen tubing was observed to be laying on the floor in the resident's room. This was evident for 1 of 3 residents reviewed for Respiratory Care (Resident #187).