Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Orchards At Wayne during CMS and state inspections, most recent first.
A therapy director applied an over-the-counter pain patch to a resident with functional quadriplegia and right leg pain without a physician's order and without nurse administration or documentation. The patch was supplied by an LPN, cut in half at the resident's request, and not recorded in the medical record or medication administration record. Facility policy and staff interviews confirmed that only licensed nurses may administer medications with a physician's order.
The facility experienced delays in meal service due to insufficient kitchen staff. Breakfast was served late, with a resident reporting receiving it at 10:00 AM instead of the scheduled time. The Dietary Manager confirmed staffing shortages, with only a cook and the manager present until 9:00 AM, instead of the required two dietary aides and one cook. The Nursing Home Administrator acknowledged the staffing issue, but no additional information was provided during the exit conference.
A resident with severe cognitive impairment and a history of traumatic brain injury was found missing from the facility and was later located by an activity aide a mile and a half away. The facility failed to promptly initiate a Code [NAME] after staff realized the resident was missing, resulting in the resident being unsupervised outside for an extended period. The charge nurse and CNA involved were terminated for not following the elopement policy.
The facility failed to prevent a physical abuse incident between two residents, where one resident, with a history of aggressive behavior, struck another resident in the face. Despite the facility's policies to prevent abuse, the incident occurred, and law enforcement was involved. The aggressive resident had a history of verbal and physical aggression towards staff, and the facility's interventions were insufficient to prevent the altercation.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as inadequate handwashing facilities, improper food labeling, and unclean equipment. Observations included cracked caulking around sinks, insufficient water temperature for handwashing, and soiled pans in the clean area. Additionally, the ice machine and kitchen walls were not properly cleaned, and meal trays were improperly handled, posing contamination risks. The NHA expected adherence to sanitary standards, but the facility did not meet these expectations.
The facility failed to maintain cleanliness in the outside dumpster area, with surveyors observing open gates and dumpsters surrounded by trash and overgrown vegetation. The District Manager of Environmental Services and Dietary Manager acknowledged the issue, and the Maintenance Director noted it would be part of preventative maintenance. The facility's waste disposal policy requires dumpsters to be clean and lids closed, but no additional information was provided during the exit conference.
A resident with obesity and chronic conditions was provided with an inadequately sized wheelchair, causing discomfort as her thighs and abdominal girth pressed against the wheelchair arms. Despite being assessed by the therapy department, the resident continued to use a standard wheelchair, which was too narrow. Both an LPN and the DON acknowledged the need for a wider wheelchair, highlighting a failure in the facility's monitoring and accommodation processes.
A resident with schizoaffective disorder and severe cognitive impairment was transferred to a hospital due to aggressive behaviors. The facility failed to notify the resident's responsible representative of the transfer, as confirmed by the DON and acknowledged by the NHA. Despite the facility's policy requiring such notification, no documentation was provided to support that the guardian was informed.
A resident with intact cognition and dependent on personal hygiene was observed with long, dirty fingernails over two days, expressing dissatisfaction with care. The care plan included nail care on bath days, but the LPN was unaware of the need until an interview. The facility's policy requires monitoring residents' needs, including nail care, which was not followed.
A facility failed to address MRR recommendations timely for a resident with multiple diagnoses, including hemiplegia and diabetes. The resident's medication regimen included Cymbalta, Abilify, Norco, and Insulin Glargine. Despite requests, the facility did not provide the pharmacy report or MRR policy before the survey concluded, leading to a noted deficiency.
The facility failed to respond to a resident's call light in a timely manner, with delays observed up to 35 minutes. The resident, who had no cognitive impairment and had requested milk, reported the call light was on for over an hour. Staff interviews revealed inconsistencies in expected response times, and the assigned CNA had been pulled to the kitchen, affecting the response time.
The facility failed to ensure pressure ulcer treatments were consistently provided as ordered for a resident with a Stage 3 pressure ulcer and Type 2 Diabetes. The resident's MDS assessment indicated a Stage 4 pressure ulcer that was not present on admission. The TAR showed multiple dates where the treatment was not documented. Observations revealed a small open area on the left ischial, and interviews confirmed that floor nurses and unit managers were responsible for wound care when the wound nurse was not present.
Unauthorized Medication Administration by Therapy Staff
Penalty
Summary
A deficiency occurred when a therapy director applied an over-the-counter pain patch to a resident without a physician's order and without the administration being performed by a licensed nurse. The resident, who had functional quadriplegia and right leg pain, reported that the therapy director applied the patch after the resident complained of pain during therapy. The patch was observed to be undated, uninitialed, and appeared to have been cut in half at the resident's request. There was no documentation of the patch application in the resident's medical record, and the medication administration record did not reflect an order for the pain patch at the time it was applied. Interviews with staff confirmed that only licensed nurses are authorized to administer medications, including over-the-counter products, and that a physician's order is required. The therapy director acknowledged applying the patch, which was supplied by an LPN, but did not document the administration. The DON confirmed that therapy staff are not permitted to administer medications and that the resident had not been evaluated for self-administration. Facility policy also requires that medications be administered and documented only by authorized personnel in accordance with physician orders.
Staffing Shortages Lead to Delayed Meal Service
Penalty
Summary
The facility failed to ensure adequate staffing in the kitchen, leading to delays in meal service. Observations and interviews revealed that breakfast was served late on multiple occasions due to insufficient staff. On the day of the survey, breakfast was supposed to be served between 8:00 AM and 9:00 AM, but a resident reported receiving breakfast at 10:00 AM. The Dietary Manager confirmed that the kitchen was short-staffed, with only a cook and the manager present until 9:00 AM, instead of the required two dietary aides and one cook. This staffing shortage caused delays in meal service throughout the day. The report also noted that the Dietary Manager had been experiencing staffing shortages for four out of the seven days they had been at the facility. The Nursing Home Administrator acknowledged that the kitchen should have been staffed with two dietary aides, one cook, and the dietary manager. Despite these staffing issues, no additional documentation or information was provided by the Nursing Home Administrator or the Director of Nursing during the exit conference.
Failure to Timely Initiate Code for Missing Resident
Penalty
Summary
The facility failed to initiate a Code [NAME] in a timely manner for a resident who was missing from the facility. The incident involved a resident with a traumatic brain injury and alcohol abuse history, who had severely impaired cognition and required extensive assistance for all activities of daily living. The resident was last seen in the facility by staff between 7:00 AM and 9:30 AM, but was later found by an activity aide approximately a mile and a half from the facility in their wheelchair. The resident had been outside and unsupervised for an extended period, which posed a potential risk for serious injury or death. The deficiency was identified when the resident was observed by an activity aide on the sidewalk, and the facility was contacted to retrieve the resident. Interviews with staff revealed that the resident was not accounted for during the day, and there was a delay in initiating the Code [NAME] after staff realized the resident was missing. The charge nurse and CNA involved in the incident were terminated for not following the facility's elopement policy. The facility's policy required immediate action when a resident was determined to be missing, but this was not followed. The resident's electronic medical record indicated that they had been assessed as low risk for elopement, with no history of wandering or exit-seeking behavior. However, the resident had made statements about leaving and was observed to be looking out. The facility's failure to promptly initiate the Code [NAME] and conduct a timely search for the resident resulted in the resident being unsupervised outside the facility for an extended period, highlighting a lapse in the facility's supervision and safety protocols.
Removal Plan
- Facility educated staff on policy of Code Green. Policy reviewed, updated, and education conducted.
- The Code [NAME] will be enacted immediately upon staff noticing that resident missing and not on appointment or LOA. Staff will page overhead Code [NAME] (Resident Room Number) three times. Staff will initiate head count of residents, search of rooms, grounds, other offices, and surrounding areas. Staff will page periodically Code [NAME] until the resident is located.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent a resident-to-resident physical abuse incident involving two residents, R701 and R702. The incident was reported to have occurred without resulting in injuries. R702 recounted that R701 approached them and their boyfriend, hitting R702 in the face and pulling on their wheelchair. R702 attempted to shield themselves but was struck in the face. A review of R702's medical record confirmed the incident, noting that R702 was hit with a closed fist on the left side of the face, neck, and shoulder by R701. Despite the assault, R702 denied experiencing pain or discomfort, and no injuries were noted at the time. Law enforcement was called, and R702 was interviewed by the police. R701's medical record revealed a history of verbal and physical aggressive behavior, including diagnoses of metabolic encephalopathy, delirium, bipolar disorder, and cognitive communication deficit. R701's care plan highlighted their risk of behaviors, including verbal aggression and impulsiveness, with interventions aimed at calming and redirecting them. On the day of the incident, R701 was verbally abusive towards staff and had attacked them before the altercation with R702. Progress notes documented R701's aggressive behavior, including an episode where they threw feces at staff and later physically assaulted R702 by running into them with a wheelchair and striking them with a closed fist. The Director of Nursing stated that R701 had not previously been abusive towards other residents, only staff. The facility's Abuse and Neglect Prohibition Policy emphasized the right of residents to be free from abuse and outlined prevention measures, including reporting signs of stress and reviewing treatment plans for residents exhibiting abusive behavior. Despite these policies, the facility failed to prevent the physical abuse incident between R701 and R702, highlighting a deficiency in protecting residents from abuse.
Sanitation and Food Safety Deficiencies in Kitchen and Meal Service
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen and food storage areas, as observed during a survey. The kitchen sinks were not in good repair, with cracked and separated caulking around the handwashing sink, and the water temperature was not warm enough for effective handwashing. Additionally, food items in the walk-in cooler were not properly date-labeled, lacking clarity on whether the dates indicated delivery, opening, or use-by dates. An undated pan of cooked mixed vegetables was found in the cooler, and the cooling log was not updated, indicating a failure to properly document the cooling process of potentially hazardous foods. Further observations revealed that pans stored in the clean pot/pan area were soiled with food debris, and the dish tank area had a black substance on the backsplash that was easily removable, indicating inadequate cleaning. The kitchen walls were not maintained in a cleanable condition, with missing cove base tiles exposing surfaces that could not be easily cleaned. The commercial ice machine was also found to have a black slimy substance on its front faceplate, which was easily removed, suggesting it had not been cleaned properly. Maintenance was reportedly responsible for cleaning the ice machine, but it had not been done. During meal service, a resident's lunch tray was retrieved from a meal cart that also contained soiled meal trays, posing a risk of food contamination. The CNA acknowledged that placing dirty trays with unserved meal trays was unsanitary. The Nursing Home Administrator expected the kitchen to maintain sanitary conditions and adhere to policies and procedures, but the facility failed to meet these standards, as evidenced by the observations and interviews conducted during the survey.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
The facility failed to properly dispose of rubbish and maintain cleanliness in the outside garbage area, leading to a visually unappealing property and the potential for pest harborage. During an observation on July 30, 2024, the gates to the fenced-in dumpster area were found open, revealing three dumpsters surrounded by overgrown vegetation and various types of trash, including a mop handle, used cups, gloves, lids, disposable food containers, plastic bags, flattened cardboard boxes, a call light pull cord, smashed cans, two metal frames, and a 55-gallon trash can half full of murky water. The middle dumpster lid was also open, which could allow animals and water to enter. The District Manager of Environmental Services and the Dietary Manager acknowledged the need for attention to the dumpster area, with the latter noting the importance of keeping the dumpster lid closed. On August 1, 2024, the Maintenance Director stated that maintaining the cleanliness of the dumpster area was a group effort and would be included in the maintenance department's preventative maintenance. The Nursing Home Administrator also mentioned the need for a cleaning schedule. The facility's waste disposal policy, reviewed during the survey, indicated that dumpsters should be maintained in a clean manner, with lids closed and the surrounding area free of debris. However, no additional documentation or information was provided during the exit conference.
Inadequate Wheelchair Sizing for Resident
Penalty
Summary
The facility failed to provide an appropriately sized wheelchair for a resident, resulting in discomfort. The resident, who was admitted to the facility with diagnoses including mononeuropathies of bilateral lower limbs and chronic congestive heart failure, was observed sitting in a standard wheelchair with an 18-inch-wide seat. The resident's abdominal girth and thighs were resting directly on the metal parts of the wheelchair arms, indicating that the wheelchair was too small. The resident expressed discomfort, stating that the wheelchair was too tight and that her legs pushed against the sides. She spends most of her day in the wheelchair, including self-propelling to the dining hall for meals. The resident's care plan noted obesity and weakness, requiring moderate help with upper body tasks and substantial help with lower body activities of daily living. The therapy department, responsible for providing wheelchairs for new admissions, assessed the resident shortly after admission. However, the assessment did not result in the provision of a properly fitting wheelchair. Both a Licensed Practical Nurse and the Director of Nursing acknowledged the need for a wider wheelchair to accommodate the resident's size. The facility's policy on unit rounds, intended to monitor residents' needs throughout the day, was not effectively implemented in this case, as the resident's discomfort was not addressed in a timely manner.
Failure to Notify Responsible Representative of Resident Transfer
Penalty
Summary
The facility failed to notify the responsible representative of a facility-initiated discharge for a resident diagnosed with schizoaffective disorder and severe cognitive impairment. The resident exhibited aggressive behaviors, including spitting, screaming, and swinging arms at staff, which led to an evaluation by a nurse practitioner. Despite these behaviors, the facility did not provide documentation that the resident's responsible representative was informed of the transfer to the hospital. The Director of Nursing confirmed the transfer to the hospital but could not provide evidence of notification to the resident's guardian. The Nursing Home Administrator acknowledged that the guardian should have been notified due to the change in the resident's condition. The facility's policy on transfers and discharges requires notification of the resident and/or their representative, but no additional documentation or information was provided during the survey exit conference.
Failure to Provide Timely Nail Care for a Resident
Penalty
Summary
The facility failed to provide timely ADL care, specifically nail care, for a resident identified as R50, resulting in dissatisfaction with care. Observations on two consecutive days revealed R50 in bed with both hands contracted into fists and long, dirty fingernails. R50, who has an intact cognition score of 15/15 and is dependent on personal hygiene, expressed the need for nail trimming. The resident's care plan, initiated in October 2022, included an intervention for nail care on bath days. However, the Licensed Practical Nurse (LPN) was unaware of the need for nail trimming until it was pointed out during an interview. The facility's policy on unit rounds includes monitoring residents' needs, such as ensuring fingernails are clean and trimmed, which was not adhered to in this case.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address Medication Regimen Review (MRR) recommendations in a timely manner for one resident, resulting in the potential for the continuance of unnecessary medications and lack of communication between the pharmacist and physician. The resident, identified as R54, was admitted with multiple diagnoses including hemiplegia, type 2 diabetes mellitus, panic disorder, schizophrenia, and bipolar disorder. The resident's medication regimen included Cymbalta, Abilify, Norco, and Insulin Glargine. A review of the clinical record on August 1, 2024, revealed that the facility did not address the pharmacist's recommendations from May 29, 2024, as the detailed pharmacy reports and recommendations were not located in the electronic medical record. During the survey, the facility was repeatedly asked to provide the pharmacy report and the facility's policy for Medication Regimen Review, but these were not provided before the survey team exited the facility. The Nursing Home Administrator acknowledged the initial request for the pharmacy report was missed but did not provide the requested documents before the survey concluded. This inaction led to the deficiency being noted by the surveyors, highlighting a lapse in the facility's process for ensuring timely communication and action on pharmacy recommendations.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to respond to a resident's call light in a timely manner, as observed on multiple occasions. On 3/20/24, a screen at the nurses' station showed that the resident's call light was on for 29 minutes at 8:14 a.m., 32 minutes at 8:17 a.m., and 35 minutes at 8:20 a.m. The resident reported that the call light had been on for over an hour before it was turned off by staff. The resident had requested milk but was told to wait. Interviews with staff revealed inconsistencies in the expected response times for call lights, ranging from 5 to 15 minutes, and it was noted that the CNA assigned to the resident had been pulled to the kitchen, affecting the response time. The resident involved had been readmitted to the facility with diagnoses including Congestive Heart Failure, End Stage Renal Disease, and Acute Pulmonary Edema. The resident had no cognitive impairment, as indicated by a BIMS score of 15. The facility's call light policy, revised on 2/17/20, stated that call lights should be answered as promptly as possible by available staff. However, the observations and staff interviews indicated that this policy was not consistently followed, leading to delays in responding to the resident's needs.
Failure to Consistently Provide Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure pressure ulcer treatments were consistently provided as ordered for one resident (R616) out of three reviewed for pressure ulcers. R616 was readmitted to the facility with a diagnosis of a Stage 3 pressure ulcer and Type 2 Diabetes. The resident's Minimum Data Set (MDS) assessment indicated no cognitive impairment and noted a Stage 4 pressure ulcer that was not present on admission. Physician orders required daily treatment of the left ischial area, but the Treatment Administration Record (TAR) showed multiple dates from December through March where the treatment was not documented. Observations on March 20 revealed a small open area on the left ischial. Interviews with the wound nurse, staff development coordinator, and director of nursing confirmed that floor nurses and unit managers were responsible for wound care when the wound nurse was not present.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Manor Rehab Center | 0.2 mi | — | 0 | 0 |
| Pine Creek Manor Skilled Nursing & Rehab Center | 0.9 mi | — | 0 | 0 |
| Imperial, A Villa Center | 3.3 mi | — | 3 | 1 |
| Cherry Hill For Nursing And Rehabilitation | 3.7 mi | — | 13 | 0 |
| Regency At Westland | 3.9 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.