Wayne County Nursing Home

Inspectors wroteBased on observations, interviews and record review conducted during an Abbreviated Survey (Intake ID: 2652860) from 11/03/2025 to 11/07/2025, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) (Resident #10) residents reviewed for accidents. Specifically, Resident #10 was transferred on 10/24/2025 using an extra-large mechanical lift sling that did not fit the resident's body size, and a registered nurse or therapist did not assess the resident upon readmission to determine the correct sling size which resulted in the resident falling from the sling and sustaining a subdural hematoma (bleeding around the brain) and an orbital fracture (fracture around the eye). [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2652860) from 11/03/2025 to 11/07/2025, the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, Resident #10 was transferred on 10/24/2025 using an extra-large mechanical lift sling that did not fit the resident's body size, and a registered nurse or therapist did not assess the resident upon readmission to determine the appropriate mode of transfer, including the mechanical lift sling size, which resulted in the resident falling from the sling and sustaining a subdural hematoma (bleeding around the brain) and an orbital fracture (fracture around the eye). [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 11/20/2024 to 11/26/2024, for four (Residents #36, #37, #91, #94) of 10 residents reviewed, the facility did not 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. Specifically, Residents #36 and #94 who were on Enhanced Barrier Precautions (a strategy in nursing homes to decrease transmission of infectious disease using enhanced personal protective equipment [PPE]) had indwelling urinary catheter drainage bags that were observed on the floor. Resident #36 received hands on care from staff who were not wearing the required personal protective equipment. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 11/20/2024 to 11/26/2024 for three (Residents #89, #119 and #130) of three residents reviewed, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medications or have medications left at their bedside unsupervised. Specifically, Resident #89 reported that nursing staff frequently left their pills in a medicine cup at their bedside for them to take later. Resident #119 had a nasal spray left unsupervised at their bedside. Resident #130 had an unlabeled and unsupervised medicine cup containing multiple pills in front of them at the table. None of the residents had an order to self-administer medications and had not been evaluated to have medications left with them unsupervised. This was evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (ACTS Reference Number: NY00329762), the facility did not ensure that an investigation was initiated following a fall to rule out abuse, neglect, or mistreatment for one (Resident #11) of three residents reviewed. Specifically, Resident #11 had a witnessed fall, and the facility was unable to provide evidence that the fall was thoroughly investigated. This is evidence by the following: The facility policy Investigations of Incidents & Allegations of Abuse, Neglect or Mistreatment, reviewed February 2024, documented the purpose is to determine a cause for an incident or accident and to determine if there is reasonable cause to believe abuse, mistreatment, or neglect took place. The results of all investigations must be reported to the administrator or designee. [...]

Inspectors wroteBased on observations, interviews and record review, conducted during the Recertification Survey, completed on 10/13/22, it was determined that for one of one main kitchen reviewed, the facility failed to store, prepare, distribute or serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there was a high temperature automatic dishwashing machine in use that did not meet temperature sanitizing standards. This is evidenced by the following: [...]

Inspectors wroteBased on interview and record review conducted during the Recertification Survey and complaint investigation (# NY00299261) completed on 10/13/22, it was determined for one (Resident #51) of one resident reviewed for notification of a change, the facility did not immediately inform the resident's representative of a transfer or discharge from the facility. Specifically, the facility did not notify the resident's primary or secondary emergency contact of a transfer to the hospital until six days after the transfer. This is evidenced by the following: Review of the facility's 'Change in Resident Status' policy revealed that to keep designated representatives apprised of changes in condition, licensed staff will call the resident's designated representative when medically ordered to transfer the resident to the hospital. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 10/13/22, it was determined that for 1 of 3 residents reviewed for behavioral, mental, and/or emotional health care services, the facility did not develop and implement a comprehensive person- centered care plan that included measurable objectives to meet all the resident's medical, nursing, mental and psychological needs as identified in their comprehensive assessments. Specifically, Resident #77's Comprehensive Care Plan (CCP) did not include goals, interventions and desired outcomes related to any behaviors such as repetitive hand movements on their body, innate objects, or the surrounding environment. This was evidenced by the following: Resident #77 had diagnoses including dementia, anxiety, and psychotic and mood disturbance. [...]

Inspectors wroteBased on interviews and record reviews, conducted during the Recertification Survey, completed on 10/13/22, it was determined that for one (Resident #15) of two residents reviewed for hospitalization, the facility did not provide services consistent with professional standards of quality. Specifically, Resident #15, who was at risk for constipation, had no documented bowel movements for more than 5 days, and the facility had not assessed the resident's condition or administered physician ordered bowel medications. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] and had diagnoses including neurocognitive disorder with Lewy bodies (form of dementia), depression and recent history of small bowel obstruction requiring hospitalization. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 3 of 31 residents reviewed for care planning, the facility did not develop or implement a plan of care for each resident that included measurable objectives and interventions to address the resident's medical, nursing, mental and psychosocial needs, or implement the plan of care. Specifically, Resident #60 did not have Dycem (rubber mat) in their wheelchair per plan of care, Resident #71 did not have a care plan developed for the use of an indwelling Foley catheter, and Resident #28 was not using and did not like the denture adhesive and it was not reported to the nurse per plan of care. This was evidenced by the following: 1. Resident #60 had diagnoses including dementia, arthritis, and a recent compression fracture of the lumbar vertebrae. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #36 and #52) of two residents reviewed for tube feedings, the facility did not provide appropriate treatment and services to prevent potential complications. Specifically, daily tube feedings and water flushes were not consistently documented or monitored to ensure physician orders were followed and resident specific tube feeding orders were not consistently completed. This is evidenced by the following: 1. Resident #36 has diagnoses including a stroke, malnutrition, dysphagia, and recent dehydration requiring intravenous fluids for 24 hours. The Minimum Data Set (MDS) Assessment, dated 10/25/19, included that the resident was cognitively intact and received 51 percent or greater of total calories via the feeding tube. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of four residents reviewed for respiratory care and oxygen, the facility did not provide proper care and treatment in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, Resident #170 had incomplete oxygen orders and the oxygen equipment was not maintained per physician orders, and Resident #71 did not have an oxygen care plan and oxygen equipment was not maintained per physician's orders. This is evidenced by the following: 1. Resident #170 has diagnoses including chronic respiratory failure, neoplasm in the left lung, and dementia. The Minimum Data Set Assessment, dated 12/14/19, revealed that the resident had severely impaired cognition and required oxygen therapy. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of seven residents reviewed for influenza and pneumococcal immunizations, the facility did not ensure that each resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications. Specifically, Resident #131 had a history of an adverse reaction to the influenza immunization. The nursing staff did not identify the adverse reaction or notify a medical provider prior to administering the immunization. This is evidenced by the following: Resident #131 was admitted to the facility on [DATE] with diagnoses including dementia, peripheral vascular disease, and hypertension. The Minimum Data Set (MDS) Assessment, dated 9/4/19, revealed that the influenza (flu) immunization was not administered due to a medical contraindication. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 24 (Residents #11, #13, #21, #22, #31, #38, #60, #76, #84, #85, #100, #108, #115, #120, #131, #134, #146, #158, #159, #164, #167, #170, #173 and #422) of 24 residents reviewed for Baseline Care Plan, the facility did not develop a Baseline Care Plan that included the minimum required healthcare information necessary to properly care for a resident, did not have documented evidence that the Baseline Care Plan was completed within the required timeframe, or did not have documented evidence that the resident or representative was provided a written summary of the Baseline Care Plan. This is evidenced by, but not limited to, the following: [...]