Wayne Healthcare Center

Inspectors wroteBased on observations, staff interviews and resident interviews, the facility failed to ensure resident's call lights were within reach, and to ensure residents did not have long waits for call lights to be answered. This failed practice had the potential to affect a limited number of residents. Resident Identifiers #6, #21, and #27. Facility Census: 59Findings Included: a) Resident #21 On 05/19/26 at12:00 PM, it was observed that Rsident #21 was laying in her bed trying to reach her call bell on the floor beside her bed causing her to almost roll out of the bed. Registered Nurse #34 was alerted, came into the room, and confirmed she was unable to get her call light and began to assist her. b) Resident # 27 On 05/20/26 at 11:59 AM Resident #27 was heard calling out for help. [...]

Inspectors wroteBased on resident interview, observation and staff interview facility failed to ensure meals are prepared and served in methods to conserve nutritive value, flavor, appearance and in a pleasing, palatable presentation. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #49, #28, #39, #18, #24,#12, #9 , #47 and #15. Facility census: 59.

Inspectors wroteBased on observation and staff interview, 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 with regards to the resident's personal products and unsanitary practices. Resident Identifier: #27. Facility census: 59Findings Included: During a facility walk-through on 05/20/26 at 12:10 PM, we observed 1 wheelchair (w/c) in the A hallway with holes in the seat, exposing the inner padding near the front left screw and 1 Geri-Chair located 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. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #23's date of an acute care transfer, the indication of a medication for Resident #3 and pressure ulcer staging for Resident #12. This was true for three (3) of 23 residents reviewed during the survey process. Resident Identifiers: #23, #3 and #12. Facility Census: 59. Findings Include: a) Resident #23 On 03/26/25 at 10:22 AM, an initial interview was held with Resident #23. Resident #23 stated, I had to go to the hospital .I was so sick. The record review found the resident had been transferred to an acute care facility on 12/04/24 due to an abnormal abdominal x-ray. The date documented on the transfer form was 08/14/24. Upon further review, the fax confirmation sheet had the date circled with a notation stating wrong date. [...]

Inspectors wroteBased on document review and staff interview, the facility failed to notify the family of one (1) of seven (7) residents that the resident had sustained a fall and was transferred to the hospital. Resident identifier: #111. Facility census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the State Ombudsman of an acute care transfer for Resident #23. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident Identifier: #23. Facility Census: 59. Findings Include: a) Resident #23 On 03/26/25 at 10:22 AM, an initial interview was held with Resident #23. Resident #23 stated, I've had to go to the hospital, I was pretty sick. A record review was completed on 03/26/25 at 1:30 PM. The review found the resident had been sent to an acute care facility on 08/14/24 for an abnormal abdominal x-ray. On 03/26/25 at 6:05 PM, an interview was held with the Administrator. The Administrator confirmed the State Ombudsman was not notified of the resident's transfer. The Administrator stated, we don't have the Ombudsman notification for 08/14/24.

Inspectors wroteBased on record review and staff interview, the facility failed to develop the care plan, which included all diagnoses for Resident #57. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #57. Facility census: 59.

Inspectors wroteb) Resident #13 Review of Resident #13's comprehensive care plan showed the following focus, The resident is at risk for pain/discomfort r/t [related to] history of left femur fracture repair s/p [status post] ORIF [open reduction internal fixation], rheumatoid arthritis, muscle spasms, diabetic neuropathy, restless leg syndrome, edema, PVD [peripheral vascular disease]. The following intervention was initiated on 09/26/24, Provide medication, Ultram, per orders. Monitor for s/sx [signs and symptoms] of side effects. Evaluate effectiveness of medication. Review of Resident #13's physicians' orders showed the resident was currently receiving gabapentin twice a day for nerve pain and Tylenol three (3) times a day for pain. The resident had received Ultram as needed from 09/25/24 through 10/09/24 and Ultram two (2) times a day from 02/03/25 through 02/17/25. [...]

Inspectors wroteBased on record Review and Staff interview, the facility failed to ensure treatment and care was provided in a timely manner for a resident with a fall with major injury for 1 out of 7 residents reviewed for falls. Resident identifier: #27. Facility Census: 59.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow accepted procedures for transmission-based precautions. These were random opportunities for discovery. Resident identifiers: #26 and #22. Facility census: 59.

Inspectors wroteBased on observation, policy review, and staff interview 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 the Long-Term Care Survey Process. This failed practice had the potential to affect all resident currently resding in the facility. Facility Census 60. Findings Include: a) Chocolate milk During the initial tour of the kitchen on 04/29/24 at 11:00 AM, ia gallon of chocolate milk was found in the reach-in-refrigerator with approximately 1/4th of the gallon of chocolate milk left in the jug. The expiration on the jug of chocolate milk was 04/26/24. A review of the facilities policy number 019, titled, { Food Storage: Cold Foods}, under policy statements reads as follows: [...]

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure a clean, sanitary environment by leaving a bedpan in the floor on the A-Hall room [ROOM NUMBER] restroom, and following policy to test yearly for Legionellosis. This failed practice had the potential to affect more than a minimal number of residents in the facility. Facility Census: 60 Findings Include: a) Bepan left in floor Observation on 04/29/24 at 11:28 AM, revealed an uncovered bedpan in bathroom floor. A second observation on 04/29/24 at 1:17 PM showed the bedpan remained on the floor in the bathroom. On 04/30/24 at 9:00 AM, a third observation with the facility Administrator who confirmed the bedpan still remained in the bathroom floor in room A13. b) Water Management/Legionella Plan Legionellosis refers to two clinically and epidemiologically distinct illnesses: [...]

Inspectors wroteBased on observation and staff interview, 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 was true for four (4) of five (5) Daily Staffing Posting forms reviewed during the long term care survey process. This had the potential to affect more than a limited number of residents. Days Identified: 04/04/24; 04/05/24; 04/12/24 and 04/18/24. Facility Census: 60.

Inspectors wroteBased on observations, family interview and staff interview the facility failed to ensure the residents were provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility failed to place chairs in the residents rooms for the resident and/or visitors to utilize. This was a random opportunity of discovery during the long term care survey process and had the potential to affect a limited number of residents. Resident Identifier: Resident #12. Census: 60. Findings Include: a) Resident #12 On 04/29/24 at 12:56 PM, during an interview with Resident #12, his brother was observed to be sitting half way on the rooms packaged terminal air conditioner (PTAC) unit beside Resident #12's bedside. Resident #12's brother stated, the room never had a chair in it but sometimes he is able to get a fold-up chair if there are any available. [...]

Inspectors wroteBased on resident observation, resident interview, and staff interview the facility failed to ensure Resident #54 was treated with dignity and respect. This was true for one (1) of seven (7) residents reviewed for the care area of dignity during the long term care survey process. Resident identifier: #54. Facility census: 60.

Inspectors wroteBased on record review and staff interview the facility failed to inform the resident or resident representative, in advance, by the physician or other practitioner or professional, of the risks and benefits of the proposed use of an antipsychotic medication. This was true for one (1) of five (5) sampled residents in the long term survey process. Resident identifier: #36. Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to issue a beneficiary notification within appropriate time frames. This was true for one (1) of three (3) residents reviewed for beneficiary notifications during the long term care survey process. Resident identifier # 111. Facility Census 60.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure the residents were provided a safe, functional, sanitary, and comfortable homelike environment. This was evident by soiled equipment, holes in walls and a dirty bathroom. These were random opportunities of discovery during the long term care survey process and had the potential to affect a limited number of residents. Resident Room Identifiers: room [ROOM NUMBER]A, Room # A14B, and Room #B14. Census: 60. Findings Include: a) room [ROOM NUMBER]A On 04/29/24 at 12:37 PM, during a tour of the facility, room [ROOM NUMBER]A was identified to have a piece of equipment in the bathroom which appeared to be soiled on the platform where you would place your feet to stand. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #30 was free from abuse which includes freedom from resident to resident altercations and #16 was free from inappropriate language from a staff member. This is true for two (2) of two (2) residents reviewed during the survey. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur and because Resident #30 did not have the cognitive ability to indicate how this affected her the reasonable person standard was applied. [...]

Inspectors wroteBased on medical record review and staff interviews the facility failed to accurately encode the residents Minimum Data Set (MDS) upon discharge. This was true for one (1) of two (2) resident discharges reviewed during the long term care survey process. Resident Identifier: Resident #59. Facility Census: 60. Findings Include: a) Resident #59 On 4/30/24 at 6:45 PM during a medical record review for Resident #59, there were no notes identified for the anticipated discharge of Resident #59 prior to the discharge occuring on 03/21/24. A review of the miscellaneous documents identified the Notice of Medicare Non-Coverage that was verbally reviewed with Resident #59's son on 03/15/24. Upon further review of the residents record, the Discharge summary dated [DATE] was completed by all required departments. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for a newly diagnosed mental illness. This was true for three (3) of four (4) residents reviewed for the PASARR care area. Resident Identifiers: #26, #41, and #52 Facility Census: 60 Findings Include: (a) Resident #26 During a record review on 04/29/24, Resident #26 medical record review revealed admitting diagnosis for 09/08/22 (admission date) included the following: -Schizoaffective disorder According to the Diagnosis Report provided by the facility the following diagnoses were added during Resident #26 stay. A review of the PASAAR submitted 03/01/23, there was no new PASARR submitted to reflect this admitting medical diagnosis (Schizoaffective disorder) or the following new diagnosis of: [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for pre admission diagnoses. This was true for two (2) of four (4) residents reviewed for the PASARR care area. Resident Identifiers: #26, #14, Facility Census: #60 Findings Include: (a) Resident #26 During a record review on 04/29/24, Resident #26 medical record revealed admitting diagnosis for 09/08/22 (admission date) included the following: -Schizoaffective disorder According to the Diagnosis Report provided by the facility and the PASARR submitted 03/01/23 the PASARR did not reflect this admitting medical diagnosis. In an interview with the Director of Nursing on 04/30/24 at 03:36 PM, it was verified the PASAAR should have reflected the Schizoaffective disorder upon the admission date of 09/08/22. [...]

Inspectors wroteBased on record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan for bowel and bladder continence. This was true for one (1) of two (2) residents reviewed for the care area of bowel and bladder continence during the long term survey process. Resident Identifiers: Resident #2. Facility Census: 60. Findings Included: a) Resident #2 On 04/30/24 at 11:20 AM, a record review of Resident #2's medical record revealed a diagnosis of urinary incontinence. Upon further record review it was noted a Urinary Incontinence Assessment was completed dated 12/22/23 noting Resident #2 was functioning incontinent requiring a toileting program titled Check and Change. During a review of Resident #2's current care plan, it was identified the facility failed to develop or implement an individualized comprehensive care plan for this diagnosis. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and record review the facility failed to provide care and services in accordance with professional standards of practice by not providing timely medical treatment for a foot injury. This was true for one (1) of 29 sampled residents reviewed during the long term care survey process. Resident identifier #52. Facility Census 60. Findings Include: a) Resident # 52 During an interview on 04/29/24 at 1:02 PM, Resident #52 who has a Brief Interview for Mental Status (BIMS) of (8) eight stated, I fell in January at my house and came here due to a broken hip. Yesterday my walker fell on the other foot, it hurt. Now I can't walk on either side. I told the nurse and she looked at it when it happened, but no one has done anything since. [...]