Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 10
Aug 29, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to medication administration, respiratory care, infection prevention and control, staffing shortages, and life safety code violations including fire safety and building maintenance issues.
Severity Breakdown
SS=D: 3
SS=F: 5
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure medication was administered and not left at bedside for Resident #338. | SS=D |
| Failed to maintain necessary respiratory care and treatments for Resident #35. | SS=D |
| Failed to follow infection control practices including PPE use and hand hygiene. | SS=D |
| Failed to maintain required minimum direct care staff to resident ratios for CNA staffing. | — |
| Wet chemical fire suppression system nozzles improperly positioned over cooking equipment. | SS=F |
| Fire alarm system smoke detection sensitivity testing not completed as required. | SS=F |
| Automatic fire sprinkler protection missing at first accessible landings in stairwells. | SS=F |
| Corridor walls had holes/penetrations compromising smoke resistance. | SS=F |
| Packaged Terminal Air Conditioner (PTAC) units filters were clogged and dirty in multiple resident rooms. | SS=E |
| Failed to inspect, maintain, and test piped-in oxygen system properly; equipment failures noted without repair records. | SS=F |
Report Facts
CNA staffing deficiency: 5
Census: 87
Sample size: 21
PTAC units with clogged filters: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Named in medication administration deficiency for Resident #338 | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration deficiency for Resident #338 | |
| Certified Nursing Assistant/Staffing Coordinator | Interviewed regarding CNA staffing deficiencies | |
| Director of Nursing | Involved in multiple deficiencies including medication administration, respiratory care, infection control, and staffing | |
| Environmental Services Director | Involved in fire safety, sprinkler system, corridor wall repairs, PTAC maintenance, and oxygen system deficiencies |
Inspection Report
Life Safety
Deficiencies: 0
Jul 18, 2023
Visit Reason
A Life Safety Code Survey was conducted as part of a new construction and renovation project involving phase 4 reconstruction of various facility areas including dining, multi-purpose rooms, corridors, toilet rooms, courtyards, and therapy gym in the basement.
Findings
CareOne at Wayne was found to be in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 NFPA 101 Life Safety Code for existing health care occupancies. The newly renovated areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Annual Inspection
Census: 57
Capacity: 74
Deficiencies: 3
Jun 23, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to be noncompliant with New Jersey staffing requirements for 9 of 14 day shifts, and had deficiencies in life safety code related to vertical openings and fire door ratings, as well as failure to complete a required three-year load bank test on the emergency generator. A time-limited waiver was requested and approved for the fire door deficiency.
Severity Breakdown
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 9 of 14 day shifts reviewed. | — |
| Four stairway exit doors on the 1st and 2nd floors were equipped with 45-minute fire-rated doors instead of the required one-hour fire rated doors. | SS=F |
| Failed to ensure the three year load bank test was completed on the existing emergency generator in accordance with NFPA 110. | SS=F |
Report Facts
Census: 57
Total Capacity: 74
Deficient Day Shifts: 9
Required CNAs vs Actual CNAs: 6
Fire Door Rating: 45
Fire Door Replacement Completion Date: Sep 25, 2023
Load Bank Test Interval: 36
Load Bank Test Completion Date: Aug 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed and acknowledged awareness of staffing ratios | |
| Director of Nursing | Acknowledged staffing ratio issues and corrective actions | |
| Licensed Nursing Home Administrator (LNHA) | Acknowledged staffing ratio issues and difficulty hiring staff | |
| Maintenance Director | Responsible for monitoring fire door compliance and generator testing |
Inspection Report
Life Safety
Deficiencies: 0
Mar 23, 2023
Visit Reason
A Life Safety Code Survey was conducted as part of a new construction and renovation project to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancies.
Findings
Care One at Wayne was found to be in compliance with the Life Safety Code requirements. The survey noted that the 2-story addition was partially completed, with the first floor SNF beds having piped medical gas, and the second floor addition occupied by Assisted Living was not observed. Phase-4 of the project was incomplete at the time of observation.
Report Facts
SNF beds with piped medical gas: 27
Inspection Report
Original Licensing
Census: 73
Capacity: 73
Deficiencies: 2
Mar 23, 2023
Visit Reason
This survey was an initial inspection for the addition of 28 new beds to the existing facility to ensure compliance with New Jersey licensure regulations.
Findings
The facility was found not in compliance with state and federal licensure regulations, specifically failing to provide the required Medicaid beds and failing to maintain the required minimum direct care staff-to-resident ratios on multiple day shifts.
Deficiencies (2)
| Description |
|---|
| Failed to provide the required Medicaid beds to comply with State and Federal licensure regulations and statutes. |
| Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey on 5 of 14 day shifts. |
Report Facts
Current beds: 73
Initial add on beds: 28
Deficient CNA staffing shifts: 5
Residents on deficient shifts: 68
Residents on deficient shifts: 67
Residents on deficient shifts: 64
Residents on deficient shifts: 62
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 1
May 20, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. A COVID-19 Focused Infection Control Survey was also conducted in conjunction with the recertification survey.
Findings
The facility was found not to be in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities. A deficiency was cited related to the improper administration of medication pens past their expiration date, failure to properly label opened medication pens, and lack of routine monitoring orders for PRN insulin. The facility was in compliance with COVID-19 infection control regulations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet professional standards of quality related to administration of medication pens past expiration date and improper labeling. | SS=D |
Report Facts
Census: 51
Sample Size: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Observed administering expired medication pen and confirmed open and expiration dates. | |
| Director of Nursing | Spoke with survey team about medication administration concerns and agreed medication should not be administered past expiration. | |
| Administrator | Spoke with survey team about medication administration concerns. |
Inspection Report
Life Safety
Deficiencies: 0
May 14, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
Care One at Wayne was found to be in compliance with the Life Safety Code requirements. The facility is a two-story building built in 2002, composed of Type II protected construction and divided into 7 smoke zones.
Inspection Report
Routine
Census: 64
Deficiencies: 0
Jan 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 41
Deficiencies: 0
Dec 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Sample size: 10
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