Wayne County Care Center

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on record review, Facility Reported Incident review, interview, and facility policy review the facility failed to ensure residents were free from staff to resident physical abuse. This deficient practice affected one resident (Resident #16) of three residents reviewed for physical abuse. The facility census was 44.|Findings Include: Review of Resident #16's medical record revealed admission date 04/09/26 with diagnoses including but not limited to traumatic hemorrhage of cerebrum, leukemia, depression, high blood pressure and anxiety. [...]

Inspectors wroteBased on record review, Facility Reporting Incident review, interview and facility policy review the facility failed to prevent misappropriation of residents' medication. This deficient practice affected one resident (Resident #14) out of one resident reviewed for misappropriation. The facility census was 44. Findings Include:Review of Resident #14's medical record revealed admission date 12/27/22 with diagnoses including but not limited to unspecified dementia, cognitive communication deficit, anxiety, and depression. Review of Resident #14's physician orders revealed an order dated 07/21/25 for antianxiety medication Clonazepam oral tablet 0.5 milligram (MG) give 0.5 MG by mouth at bedtime. Review of Resident #14's Medication Administration Record (MAR) dated 08/01/25 to 08/30/25 revealed Clonazepam was marked as administered per order on 08/19/25. [...]

Inspectors wroteBased on Facility Reporting Incident review, interview, and facility policy review the facility failed to report misappropriation of residents' pain medication Oxycodone. This deficient practice affected seven residents (Residents #6, #13, #14, #18, #24, #45, and #47) out of seven reviewed for use of pain medication Oxycodone. The facility's census was 44. Findings Include:Review of the Facility Reporting Incident (FRI) #264336 dated 08/20/25 and closed 08/25/25 revealed during the investigation Licensed Practical Nurse (LPN) #401 was required to complete a urine drug test for Clonazepam on 08/20/25. The facility received LPN #401's drug test results on 09/04/25 revealing LPN #401 tested positive for Oxycodone without an active prescription. LPN #401 resigned from employment at the facility on 09/19/25. [...]

Inspectors wroteBased on record review, observation, interview and facility policy review the facility failed to ensure Enhanced Barrier Precautions were followed during indwelling urinary catheter care. This deficient practice affected one resident (Resident #11) of one resident reviewed for indwelling urinary catheter. The facility census was 44. Findings Include:Review of Resident #11's medical record revealed admission date 01/16/26 with diagnoses including but not limited to rectum cancer, high blood pressure, obstructive and reflux uropathy, and epilepsy. Review of Resident #11's discharge return anticipated [NAME] Data Set (MDS) dated [DATE] revealed Resident #11 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of eight out of a possible 15 and had an indwelling urinary catheter. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents who wanted the facility to manage resident funds had a signed authorization for the facility to manage their resident funds. This affected two residents (#19 and #37) out of 24 residents with resident funds. Findings Include: Review of the Resident Funds for Resident #19 revealed the current balance of $2,210.05 in the Resident funds account, There was no documentation that Resident #19 signed authorization for the facility to manage his resident funds. Review of the Resident Funds for Resident #37 revealed the currant balance of $3,716.61 in the Resident funds account. There was no documentation that Resident #37 signed authorization for the facility to manage his resident funds. Interview on 11/12/24 at 3:01 P.M. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents receive a spend down notice prior to reaching the maximum allowed limit for Medicaid benefits. This affected two residents (Resident #4 and #19) out of 24 residents with resident funds. Findings Include: Review of the Resident Funds for Resident #19 revealed a balance of $3,716.61 in the Resident Funds account. The facility is to notify the resident when their account reaches $200 below the allotted amount ($2000), which could cause the resident to lose their Medicaid benefits. Review of the Resident Funds for Resident #4 revealed a balance of $4,814.47 in the Resident Funds account. The facility is to notify the resident when their account reaches $200 below the allotted amount ($2000), which could cause the resident to lose their Medicaid benefits. Interview on 11/12/24 at 3:01 P.M. [...]

Inspectors wroteBased on review of the medical record, review of therapy assessments, and staff interview, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to Resident #41. This affected one resident (#41) of two reviewed for beneficiary notification. The facility census was 37.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to change the oxygen tubing in a timely manner for Resident #8. This affected one resident (#8) of one reviewed for oxygen use. The facility census was 37.

Inspectors wroteBased on a Self-Reported Incident (SRI) review, record review, review of hospital records, facility investigation review, personnel file review, staff interviews, and facility policy review the facility failed to provide adequate staff assistance during resident care resulting in a fall with major injury. Actual harm occurred on 07/24/24 at 4:20 A.M. when State Tested Nursing Assistant (STNA) #300 was providing incontinence care to Resident #6, who required two staff assistance with bed mobility, repositioned the resident onto her right side and Resident #6 kicked her left leg out and began sliding out of the bed and landed on her right side. The resident sustained bruising to her right hand, left eye, left shin, left index finger, right upper chest and right forearm, a skin tear to left hand third digit and pain to right leg and hip. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Resident #16's advance directive wishes were accurately documented and consistent throughout the medical record. This affected one resident (#16) of 16 residents whose records were reviewed for advance directives.

Inspectors wroteBased on record review and interview the facility failed to ensure timely provision of dental services for Resident #11. This affected one resident (#11) of three residents reviewed for dental services.

Inspectors wroteBased on observation and interview the facility failed to provide a clean and sanitary kitchen for food storage and preparation. This affected 46 out of 47 residents who received meals from the dietary department (Resident #36 did not receive meals prepared by dietary staff).