Inspection Reports for Complete Care At Wayne Hills Rehab & Resp Center
130 Terhune Drive, NJ, 07470
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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 details the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health 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
Complaint Investigation
Census: 85
Deficiencies: 3
Sep 10, 2024
Visit Reason
The inspection was conducted based on a complaint (NJ00176749) alleging failure to report and investigate an incident involving Resident #2 as required by state and federal regulations.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to report alleged violations of abuse and failure to investigate such allegations timely and properly. The facility also failed to meet minimum staffing ratios for certified nurse aides on multiple day shifts prior to the survey.
Complaint Details
Complaint NJ00176749 involved failure to report and investigate an alleged incident of abuse involving Resident #2. The facility staff did not report the incident to the New Jersey Department of Health as required and failed to investigate the allegation properly. The facility acknowledged the failure to follow policy and regulatory requirements.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment within required timeframes. | SS=D |
| Failure to thoroughly investigate alleged violations of abuse, neglect, exploitation, or mistreatment and report investigation results within required timeframes. | SS=D |
| Failure to meet minimum staffing ratios for Certified Nurse Aides (CNAs) on 13 of 14 day shifts reviewed prior to survey. | — |
Report Facts
Census: 85
Sample Size: 4
Deficient CNA staffing days: 13
Residents: 86
Required CNAs: 11
Actual CNAs: 8
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 3
Sep 26, 2023
Visit Reason
A Focused Infection Control Survey was conducted by the New Jersey Department of Health due to a complaint regarding failure to follow CDC infection control guidance during an outbreak involving Carbapenem-resistant Acinetobacter baumannii and Candida Auris.
Findings
The facility failed to implement proper infection control surveillance and PPE use, including staff not donning required PPE correctly before entering rooms with Transmission Based Precautions. The facility also lacked accurate infection surveillance tracking and documentation during the outbreak.
Complaint Details
Complaint NJ # 167624 regarding failure to follow CDC infection control guidance and PPE use during an outbreak of Carbapenem-resistant Acinetobacter baumannii and Candida Auris.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement infection control surveillance per facility policy during an outbreak of Carbapenem-resistant Acinetobacter baumannii and Candida Auris. | SS=F |
| Staff failed to don required personal protective equipment properly prior to entering resident rooms on Transmission Based Precautions, risking cross contamination. | SS=F |
| Facility did not maintain accurate and timely surveillance line lists for infections during the outbreak. | SS=F |
Report Facts
Census: 90
Sample size: 3
Completion date for plan of correction: Oct 25, 2023
Audit frequency: 5
Audit duration: 4
Audit duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Observed not properly securing PPE gown and not performing hand hygiene before entering isolation room | |
| Licensed Practical Nurse Infection Preventionist (LPN-IP) | Interviewed regarding infection control practices and surveillance; acknowledged deficiencies and provided corrected line lists | |
| Director of Nursing (DON) | Interviewed regarding PPE use and infection control; stated PPE gowns should not be worn in hallways |
Inspection Report
Routine
Census: 78
Deficiencies: 8
Feb 23, 2022
Visit Reason
The facility underwent a standard routine survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance with professional standards of care, medication administration, respiratory care, dialysis assessments, pharmacy services, medication labeling and storage, food safety, and infection prevention and control. Deficiencies were cited in multiple areas including failure to document medication sites, failure to follow physician orders for therapy, inadequate dialysis assessments, inaccurate controlled medication inventories, improper medication labeling and storage, unsanitary food handling, and breaches in infection control practices.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to document injection sites on electronic Medication Administration Record for one resident. | SS=D |
| Failure to ensure respiratory therapy was administered according to physician's orders for two residents. | SS=D |
| Failure to consistently assess a resident upon return from dialysis. | SS=D |
| Failure to ensure accurate inventory and accountability of controlled medications in the automated medication dispensing system. | — |
| Failure to properly label, store, and dispose of medications in medication carts, including expired medications and unlocked narcotic boxes. | SS=D |
| Failure to store potentially hazardous foods properly, sanitize and air-dry steam table pans, and maintain kitchen environment and equipment in a sanitary manner. | SS=D |
| Failure to follow accepted infection control standards including hand hygiene, proper use of personal protective equipment, and cleaning protocols by nursing and housekeeping staff. | SS=E |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
Report Facts
Census: 78
Sample Size: 21
Deficiency counts: 8
Staffing ratios: 8
Staffing ratios: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Involved in re-educating nurses on medication documentation and infection control. | |
| Director of Nursing | Responsible for reviewing medication administration documentation and monitoring corrective actions. | |
| Licensed Practical Nurse (LPN #1) | Observed breaching infection control during wound treatment. | |
| Licensed Practical Nurse (LPN #2) | Observed breaching infection control and improper wound care technique. | |
| Housekeeper #1 | Observed breaching infection control protocols related to PPE and hand hygiene. | |
| Housekeeper #2 | Observed breaching infection control protocols related to PPE and disposal of eye protection. | |
| Housekeeper #3 | Observed breaching infection control protocols related to hand hygiene. | |
| Licensed Nursing Home Administrator | Interviewed regarding staffing shortages and medication accountability. | |
| Regional Clinical Specialist | Interviewed regarding medication accountability and staffing. |
Inspection Report
Routine
Census: 92
Deficiencies: 0
Feb 4, 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 and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Jan 11, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ00142195.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint # NJ00142195 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Dec 2, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00140713.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint # NJ00140713 was investigated and the facility was found compliant.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 82
Deficiencies: 0
Nov 25, 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 related to COVID-19.
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
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