Wayne County Care Center

In the surveyor’s words

From the most serious findings on record at Wayne County Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 10, 2024

  Based 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. […]

• No harm, potential for more than minimal, isolatedF600May 14, 2026

  THE 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.Review of Resident #16's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had severely impaired cognition with a… […]

• No harm, potential for more than minimal, isolatedF602May 14, 2026

  Based 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… […]

• No harm, potential for more than minimal, isolatedF609May 14, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF880May 14, 2026

  Based 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… […]