Inspection Reports for
Wayne Center for Nursing & Rehabilitation
3530 Wayne Avenue, Bronx, NY, 10467
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 2
Date: Jan 21, 2025
Visit Reason
The inspection was conducted as a recertification survey combined with complaint investigations to assess compliance with care standards and safety regulations.
Complaint Details
The complaint investigation (NY00342658) found that Resident #290 fell out of bed due to inadequate staffing during care. The incident was substantiated, and the Certified Nursing Assistant involved was suspended and educated upon return.
Findings
The facility failed to ensure proper monitoring and maintenance of a peripheral intravenous site for one resident, and failed to prevent an accident resulting in a resident falling out of bed and sustaining a skin tear. Both deficiencies were found to have minimal harm with few residents affected.
Deficiencies (2)
F 0684: The facility did not ensure that Resident #187 received appropriate monitoring and maintenance of the peripheral intravenous site, including timely dressing changes and documentation as required by policy.
F 0689: The facility did not ensure adequate supervision to prevent accidents, resulting in Resident #290 falling out of bed and sustaining a 2.5 cm skin tear during care when only one staff member was present.
Report Facts
Residents reviewed for accidents: 3
Residents sampled: 38
Resident #290 skin tear size: 2.5
Resident #290 skin tear width: 1
Intravenous infusion rate: 60
Duration of intravenous infusion: 72
Zosyn administration frequency: 3
Zosyn administration duration: 5
Peripheral intravenous dressing change interval: 3
Certified Nursing Assistant suspension duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Unit Manager | Interviewed regarding intravenous dressing maintenance for Resident #187 |
| Director of Nursing | Interviewed regarding peripheral intravenous line policy and Resident #290 fall investigation | |
| Certified Nursing Assistant #3 | CNA | Involved in care during Resident #290 fall and subsequently suspended |
| Registered Nurse #3 | RN | Interviewed after Resident #290 fall and assessed resident |
Inspection Report
Annual Inspection
Census: 38
Capacity: 243
Deficiencies: 7
Date: Jan 21, 2025
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including incomplete and untimely care plan development and review, inadequate respiratory care and oxygen order documentation, insufficient nursing staff especially on weekends and nights, improper food storage and sanitation practices, improper garbage disposal, and lack of Medical Director participation in Quality Assurance meetings.
Deficiencies (7)
10NYCRR415.11(c)(1) The facility did not develop and implement a comprehensive care plan for Resident #46's diagnosis of Osteoporosis after hospital readmission.
10NYCRR415.11(c)(2) The facility failed to review and revise comprehensive care plans quarterly for Residents #74 and #187 after assessments.
415.12(k)(6) The facility did not ensure oxygen therapy was provided with proper physician orders and did not date or change nasal cannula tubing weekly for Residents #19 and #187.
10 NYCRR 415.13(a)(1)(i-iii) The facility had ongoing weekend and night shift nursing staff shortages, confirmed by staffing data and resident interviews.
10 NYCRR 415.14(h) The facility stored expired and unlabeled food items in refrigerators and pantry units, and failed to maintain proper food safety standards.
10 NYCRR 415.14(h) The facility failed to properly dispose of garbage and maintain sanitary conditions in garbage storage areas; the outside compactor lid was left open and uncovered.
10 NYCRR 415.15(a) The Medical Director did not participate in quarterly Quality Assurance and Performance Improvement meetings as required.
Report Facts
Residents sampled: 38
Facility capacity: 243
Staff shortages: 30
Oxygen flow rate: 2
Oxygen flow rate: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Registered Nurse Manager | Named in care plan deficiency for Resident #46 |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan processes, oxygen orders, staffing, and QAPI meetings |
| Registered Nurse #7 | Registered Nurse | Interviewed regarding care plan updates for Resident #74 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about oxygen use for Resident #19 |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about oxygen order and tubing for Residents #19 and #187 |
| Registered Nurse #5 | Unit Manager | Interviewed about oxygen order for Resident #19 |
| Dietary Supervisor #1 | Dietary Supervisor | Interviewed regarding food storage and garbage disposal deficiencies |
| Dietary Aide #1 | Dietary Aide | Observed and interviewed regarding garbage disposal practices |
| Registered Nurse #4 | Unit Manager | Interviewed regarding pantry refrigerator food labeling and cleaning |
| Registered Nurse #1 | Unit Manager | Interviewed regarding pantry refrigerator food labeling and cleaning |
| Administrator | Facility Administrator | Interviewed regarding staffing and Medical Director attendance at QAPI meetings |
| Medical Director | Medical Director | Interviewed regarding participation in QAPI meetings |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Jan 21, 2025
Visit Reason
Multiple Level 2 standard health and life safety code citations related to care planning, food safety, accident hazards, infection control, quality of care, nursing staff sufficiency, and sprinkler system maintenance. All deficiencies corrected by March 2025.
Findings
Multiple Level 2 standard health and life safety code citations related to care planning, food safety, accident hazards, infection control, quality of care, nursing staff sufficiency, and sprinkler system maintenance. All deficiencies corrected by March 2025.
Deficiencies (11)
Care plan timing and revision
Develop/implement comprehensive care plan
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection control
Quality of care
Respiratory/tracheostomy care and suctioning
Responsibilities of medical director
Sufficient nursing staff
Sprinkler system - maintenance and testing
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 20, 2023
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 21, 2022
Visit Reason
One Level 2 standard health citation for advance directive treatment refusal documentation; corrected by March 2023.
Findings
One Level 2 standard health citation for advance directive treatment refusal documentation; corrected by March 2023.
Deficiencies (1)
Request/refuse/dscntnue trmnt;formlte adv dir
Inspection Report
Recertification
Deficiencies: 6
Date: Dec 19, 2022
Visit Reason
Recertification and complaint survey conducted to assess compliance with regulatory requirements including physical restraints, abuse reporting, care planning, mobility, and food safety.
Complaint Details
Complaint investigation revealed failure to timely report resident-to-resident abuse involving residents #49 and #148. The allegation was reported 44 hours after the incident, exceeding the required 2-hour timeframe.
Findings
The facility failed to ensure residents were free from unnecessary physical restraints, timely abuse reporting, accurate Minimum Data Set (MDS) assessments, resident/family participation in care planning, proper application of mobility devices, and safe food storage and infection control practices.
Deficiencies (6)
F 0604: Facility did not ensure residents #58 and #112 were free from physical restraints as ongoing re-evaluation assessments for bilateral side rails were not conducted.
F 0609: Facility failed to report resident-to-resident abuse allegations within 2 hours to the State Survey Agency for residents #49 and #148.
F 0641: Minimum Data Set (MDS) assessments did not accurately document falls and use of side rails for residents #37, #58, and #112.
F 0657: Facility did not ensure residents #112 and #37 or their representatives were offered opportunity to participate in care plan reviews, especially quarterly meetings.
F 0688: Resident #208 with limited range of motion did not receive treatment as ordered; right knee orthosis was not applied or documented.
F 0812: Facility failed to ensure safe food storage with expired food items found and staff did not perform hand hygiene during meal service, risking infection transmission.
Report Facts
Residents reviewed for Physical Restraints: 7
Sample size: 39
Delay in abuse reporting: 44
Expired syrup bottles: 7
Expired vinegar gallons: 4
Expired cottage cheese containers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nursing Assistant | Interviewed regarding Resident #58's use of side rails |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding Resident #58's involuntary movements and side rails |
| RN #3 | Registered Nurse | Interviewed regarding side rails assessment responsibilities |
| MD | Medical Doctor | Interviewed regarding side rails use for Residents #58 and #112 |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding Resident #112's use of side rails |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding Resident #112's involuntary movements and side rails |
| RN #2 | Registered Nurse | Interviewed regarding abuse incident reporting |
| ADON | Assistant Director of Nursing | Interviewed regarding abuse incident reporting and care plan participation |
| DON | Director of Nursing | Interviewed regarding abuse reporting, side rails, and care plan participation |
| Administrator | Facility Administrator | Interviewed regarding abuse reporting timelines |
| DMDS | Director of Minimum Data Set | Interviewed regarding MDS assessment accuracy |
| MDSA | MDS Assessor | Interviewed regarding MDS coding errors |
| DSS | Director of Social Services | Interviewed regarding care plan meeting invitations |
| RN #1 | Registered Nurse | Interviewed regarding application and documentation of Resident #208's knee orthosis |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding Resident #208's knee orthosis application |
| SPT | Senior Physical Therapist | Interviewed regarding splint orders and documentation |
| FSD | Food Service Director | Interviewed regarding expired food items and food storage practices |
| DA #1 | Dietary Aide | Interviewed regarding expired food items and food storage |
| RNS #2 | Registered Nurse Supervisor | Interviewed regarding hand hygiene during meal service |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Dec 19, 2022
Visit Reason
Multiple Level 2 standard health and life safety code citations including assessments accuracy, care planning, food safety, accident hazards, mobility, reporting violations, restraints, and multiple life safety code issues; all corrected by February 2023.
Findings
Multiple Level 2 standard health and life safety code citations including assessments accuracy, care planning, food safety, accident hazards, mobility, reporting violations, restraints, and multiple life safety code issues; all corrected by February 2023.
Deficiencies (16)
Accuracy of assessments
Care plan timing and revision
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Increase/prevent decrease in rom/mobility
Reporting of alleged violations
Right to be free from physical restraints
Building construction type and height
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Gas and vacuum piped systems - central supply
Horizontal sliding doors
Physical environment
Sprinkler system - installation
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 15, 2022
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jun 21, 2022
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 23, 2022
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 9, 2022
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 29, 2021
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 13, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing care and infection control at the facility.
Findings
The facility failed to ensure that a resident received ordered splinting devices to prevent contracture worsening, and infection control practices were inadequate as oxygen tubing was found on the floor. Both deficiencies were noted with minimal harm and affected a few residents.
Deficiencies (2)
F 0688: The facility did not provide ordered bilateral elbow extension and hand splints to Resident #53, resulting in lack of prevention of contracture worsening. Splints were missing for multiple days and nursing documentation was incomplete.
F 0880: The facility failed to maintain infection control as Resident #187's oxygen tubing was observed lying on the floor, posing contamination risk. Staff did not promptly address the issue.
Report Facts
Residents affected: 1
Residents affected: 1
Days splints missing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Charge Nurse | Responsible for overseeing medication nurses and CNAs on resident's unit; interviewed about splinting device orders and usage |
| CNA #2 | Certified Nursing Assistant | Worked with Resident #53; unable to find splints in resident's room |
| RN #1 | Registered Nurse | Observed oxygen tubing on floor and acknowledged need to replace it |
| Director of Nursing | Director of Nursing | Interviewed regarding splinting device procedures and infection control improvements |
| Occupational Therapist | Occupational Therapist | Provided discharge summary and education on splinting devices |
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