Inspection Reports for Complete Care At Wayne Hills Rehab & Resp Center
130 Terhune Drive, Wayne, NJ, 07470
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of deficiencies related to resident care, including failure to provide assistance with activities of daily living and wound care, as well as issues with reporting and investigating abuse allegations. Complaint investigations substantiated failures in timely reporting and investigation of abuse, and inspectors cited infection control deficiencies during an outbreak of multi-drug resistant organisms. Enforcement actions included an Immediate Jeopardy finding in July 2025 related to abuse reporting, which was resolved promptly, and no fines or license suspensions were listed in the available reports. The facility’s record shows some improvement over time, with recent inspections free of deficiencies following earlier citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
85 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: 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
Deficiencies: 2
Date: Nov 12, 2025
Visit Reason
The inspection was conducted based on complaints #2624450 and #2661339 regarding failure to provide necessary assistance with activities of daily living, specifically assistance with breakfast for a dependent resident, and failure to provide ordered wound care.
Complaint Details
Complaint #2624450 and #2661339 were substantiated based on interviews, record reviews, and facility documentation indicating failure to provide necessary assistance with activities of daily living and wound care as ordered.
Findings
The facility failed to ensure that Resident #2 received assistance with breakfast as required by their care plan, and failed to provide ordered wound care treatments for Residents #1 and #2, with multiple treatment administration records showing blank entries indicating treatments were not completed as ordered.
Deficiencies (2)
Failure to provide care and assistance to perform activities of daily living for a resident dependent on staff, specifically assistance with breakfast.
Failure to provide appropriate wound care as ordered by the physician, with multiple missed treatments documented in treatment administration records for two residents.
Report Facts
Residents reviewed for ADLs: 3
Residents reviewed for wound care: 2
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding meal assistance and wound care responsibilities | |
| Director of Social Services (DSS) | Interviewed regarding observation of Resident #2's untouched breakfast tray |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 18, 2025
Visit Reason
The inspection was conducted based on a complaint alleging failure to protect a cognitively impaired resident from abuse when the resident was found tied to their wheelchair by a roommate, and the incident was not reported promptly.
Complaint Details
Complaint #: NJ00183653. The complaint investigation found that on 01/15/2025, Resident #1 was tied to their wheelchair by Resident #3 and the incident was not reported by CNA #1. Resident #1 remained with Resident #3 until 01/16/2025. The facility was notified of the Immediate Jeopardy on 07/15/2025 and submitted a Removal Plan on 07/17/2025. The Immediate Jeopardy was verified resolved on 07/18/2025.
Findings
The facility failed to implement its abuse policy by not immediately reporting and investigating the incident where Resident #1 was tied to their wheelchair by Resident #3. This failure placed residents at risk and resulted in an Immediate Jeopardy situation that was later addressed by a Removal Plan and corrective actions.
Deficiencies (1)
Failure to protect residents from abuse including physical restraint by another resident and failure to immediately report and investigate the incident.
Report Facts
Residents reviewed for abuse: 7
BIMS score: 0
Dates of incident: Jan 15, 2025
Dates of survey: Jul 14, 2025
Dates of survey: Jul 15, 2025
Dates of survey: Jul 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Observed Resident #1 tied to wheelchair but did not report the incident |
| LPN #1 | Licensed Practical Nurse | Provided care to Resident #1 and reported observations related to the incident |
| Director of Nursing | Director of Nursing (DON) | Reviewed incident report and acknowledged failures in reporting and resident protection |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment within required timeframes.
Failure to thoroughly investigate alleged violations of abuse, neglect, exploitation, or mistreatment and report investigation results within required timeframes.
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: 85
Deficiencies: 2
Date: Sep 10, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility staff failed to report and investigate an allegation of sexual abuse made by a resident to the New Jersey Department of Health as required.
Complaint Details
Complaint #: NJ00176749. The complaint alleged failure to report and investigate sexual abuse by Resident #2. The allegation was substantiated by interviews and record reviews.
Findings
The facility failed to timely report and investigate an allegation of sexual abuse involving Resident #2. The Director of Nursing and Licensed Nursing Home Administrator acknowledged not following state and federal regulations or the facility's policy for reporting and investigating abuse allegations.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to investigate an alleged incident of sexual abuse as required.
Report Facts
Census: 85
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Acknowledged failure to report and investigate the sexual abuse allegation | |
| Licensed Nursing Home Administrator (LNHA) | Acknowledged failure to report and investigate the sexual abuse allegation | |
| Social Worker | Stated the sexual abuse allegation was not reported to her directly and acknowledged responsibility to ensure resident safety |
Inspection Report
Routine
Deficiencies: 5
Date: May 24, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident assessments, documentation accuracy, respiratory care, and physician oversight.
Findings
The facility was found deficient in timely submission and accurate coding of Minimum Data Set (MDS) assessments for residents, proper documentation of bowel elimination status, appropriate respiratory care including oxygen therapy management, and ensuring physicians sign monthly orders and write progress notes as required.
Deficiencies (5)
Failure to complete and submit electronically the Minimum Data Set (MDS) within 14 days of assessment for 1 of 20 residents.
Failure to accurately code the Minimum Data Set (MDS) for 2 of 20 residents reviewed for accuracy of MDS coding.
Failure to maintain nursing professional standards by not accurately documenting bowel elimination status for 1 of 20 residents reviewed.
Failure to provide safe and appropriate respiratory care by not ensuring oxygen nasal cannula was properly positioned and tubing was dated for 1 resident observed for respiratory care.
Failure to ensure resident's primary physicians signed and dated monthly physician orders and wrote progress notes every other month for 10 of 20 residents over a 6-month period.
Report Facts
Residents reviewed for MDS coding accuracy: 20
Residents affected by MDS submission deficiency: 1
Residents affected by inaccurate MDS coding: 2
Residents affected by bowel elimination documentation deficiency: 1
Residents affected by respiratory care deficiency: 1
Residents affected by physician order and progress note deficiencies: 10
Date of survey completion: May 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator/Registered Nurse (MDSC/RN) | Interviewed regarding MDS submission and coding deficiencies | |
| Director of Clinical Services (DCS) | Interviewed regarding bowel elimination documentation and staff education | |
| Certified Nurse Assistant (CNA) | Interviewed regarding resident bowel movement schedule | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding bowel movement documentation and oxygen therapy | |
| Regional MDS Coordinator (MDSC) | Provided validation report and information on MDS submission | |
| Regional Clinical Registered Nurse (RCRN) | Part of administrative team interviewed about oxygen therapy concerns | |
| Regional Administrator (RA) | Part of administrative team interviewed about oxygen therapy concerns | |
| Director of Nursing (DON) | Part of administrative team interviewed about oxygen therapy concerns and physician visit issues | |
| Licensed Nursing Home Administrator (LNHA) | Part of administrative team interviewed about physician visit and order signage concerns | |
| Registered Nurse #2 | Interviewed about physician visits frequency | |
| Nurse Practitioner (NP) | Mentioned in relation to resident care and interviews |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
Failure to implement infection control surveillance per facility policy during an outbreak of Carbapenem-resistant Acinetobacter baumannii and Candida Auris.
Staff failed to don required personal protective equipment properly prior to entering resident rooms on Transmission Based Precautions, risking cross contamination.
Facility did not maintain accurate and timely surveillance line lists for infections during the outbreak.
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
Annual Inspection
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the Complete Care at Wayne Hills Rehab & Resp Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 26, 2023
Visit Reason
The inspection was conducted in response to Complaint NJ #167624 regarding the facility's failure to follow CDC guidance and implement infection control practices to mitigate the spread of multi-drug resistant organisms (MDROs) during an outbreak beginning on 09/15/2023.
Complaint Details
Complaint NJ #167624 regarding infection control failures during an MDRO outbreak was substantiated based on observations, interviews, and documentation review.
Findings
The facility failed to implement infection control surveillance for MDROs including Carbapenem-Resistant Acinetobacter Baumannii (CRAB) and Candida Auris, and staff failed to properly don required personal protective equipment (PPE) prior to entering resident rooms under Transmission Based Precautions. Multiple observations and interviews confirmed improper PPE use and lack of adequate surveillance documentation.
Deficiencies (2)
Failure to implement infection control surveillance per facility policy for MDROs including CRAB and Candida Auris.
Staff did not don required PPE properly prior to entry to resident rooms on Transmission Based Precautions, including unsecured PPE gowns and failure to perform hand hygiene or don gloves.
Report Facts
Resident names on CRAB Line List: 16
Residents with positive test results on initial CRAB Line List: 14
Resident names on corrected CRAB Line List: 12
Residents with positive test results on second corrected CRAB Line List: 10
Resident names on third corrected CRAB Line List: 11
Residents with positive test results on third corrected CRAB Line List: 9
Resident names on C. Auris Line List: 8
Resident names on corrected C. Auris Line List: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Observed improperly wearing PPE and entering resident room without proper precautions | |
| Licensed Practical Nurse Infection Preventionist (LPN-IP) | Interviewed regarding PPE use and infection control surveillance; provided line lists and acknowledged errors | |
| Director of Nursing (DON) | Interviewed regarding PPE use and infection control practices; stated PPE gowns should not be worn in hallways |
Inspection Report
Routine
Census: 78
Deficiencies: 8
Date: 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.
Deficiencies (8)
Failure to document injection sites on electronic Medication Administration Record for one resident.
Failure to ensure respiratory therapy was administered according to physician's orders for two residents.
Failure to consistently assess a resident upon return from dialysis.
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.
Failure to store potentially hazardous foods properly, sanitize and air-dry steam table pans, and maintain kitchen environment and equipment in a sanitary manner.
Failure to follow accepted infection control standards including hand hygiene, proper use of personal protective equipment, and cleaning protocols by nursing and housekeeping staff.
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
Deficiencies: 7
Date: Feb 23, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, respiratory care, dialysis care, pharmaceutical services, medication labeling and storage, food safety, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to document injection sites for medications, inadequate respiratory care and oxygen therapy administration, inconsistent dialysis access site assessments, failure to maintain accurate controlled medication inventories, improper medication labeling and storage, unsafe food storage and sanitation practices, and breaches in infection prevention and control practices by nursing and housekeeping staff.
Deficiencies (7)
Failure to document injection sites on the electronic Medication Administration Record (eMAR) for 1 of 18 residents.
Failure to provide safe and appropriate respiratory care and oxygen therapy in accordance with physician's orders for 2 of 6 residents.
Failure to consistently assess a resident upon return from dialysis, including lack of documentation of dialysis access site assessments.
Failure to ensure an accurate inventory of controlled medications dispensed from the facility's automated medication dispensing system (AMDS), including missing accountability forms and inability to print controlled medication usage reports.
Failure to properly label, store, and dispose of medications in 3 of 6 medication carts inspected, including expired insulin, unlabeled opened medications, and unlocked narcotic boxes.
Failure to store potentially hazardous foods properly, sanitize and air-dry steam table pans, and maintain kitchen environment and equipment in a sanitary manner to prevent contamination and food borne illness.
Failure to follow accepted infection prevention and control practices by nursing and housekeeping staff, including improper use and sanitation of wound care equipment, failure to perform hand hygiene, and improper use of personal protective equipment (PPE).
Report Facts
Residents reviewed for injection site documentation: 18
Residents reviewed for respiratory care: 6
Residents reviewed for dialysis care: 1
Medication carts inspected: 6
Dates missing nurse signatures on narcotic count accountability forms: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control breach during wound treatment of Resident #42. |
| LPN #2 | Licensed Practical Nurse | Named in infection control breach during wound treatment of Resident #21 and medication cart inspection. |
| LPN #3 | Licensed Practical Nurse | Named in medication cart inspection and infection control observation. |
| HK #1 | Housekeeper | Named in infection control breaches related to PPE use and hand hygiene. |
| HK #2 | Housekeeper | Named in infection control breaches related to PPE use and disposal of used eye protection. |
| HK #3 | Housekeeper | Named in infection control breaches related to PPE use and hand hygiene. |
| Regional Clinical Specialist | Registered Nurse | Interviewed regarding medication accountability and facility practices. |
| Licensed Nursing Home Administrator | Administrator | Interviewed regarding medication accountability and facility policies. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication accountability and facility policies. |
| Provider Pharmacy Account Manager | Pharmacy Account Manager | Interviewed regarding responsibilities for medication dispensing system. |
| Respiratory Therapist | Respiratory Therapist | Interviewed regarding oxygen therapy and care plans for residents. |
| Respiratory Therapist Director | Respiratory Therapist Director | Interviewed regarding oxygen therapy orders and staff responsibilities. |
| Registered Nurse Unit Manager | Registered Nurse Unit Manager | Interviewed regarding dialysis resident assessments. |
| Housekeeping Director | Housekeeping Director | Interviewed regarding infection control practices and staff education. |
Inspection Report
Routine
Census: 92
Deficiencies: 0
Date: 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
Date: Jan 11, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ00142195.
Complaint Details
Complaint # NJ00142195 was investigated and the facility was found to be in substantial compliance.
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.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00140713.
Complaint Details
Complaint # NJ00140713 was investigated and the facility was found compliant.
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.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: 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
Inspection Report
Routine
Deficiencies: 3
Date: Jan 6, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing facility services, including medication administration, resident care planning, and psychotropic medication monitoring.
Findings
The facility was found deficient in accurately documenting nutritional supplement consumption for one resident, failing to assess and develop a care plan for a resident with limited mobility using a trapeze bar, and inconsistently monitoring and documenting the effects of increased doses of psychotropic medication for another resident. These deficiencies were associated with minimal harm or potential for actual harm and affected a few residents.
Deficiencies (3)
Facility staff failed to follow physician's orders to accurately document in the electronic Medication Administration Record (eMAR) the amount of a nutritional supplement administered to Resident #47.
Facility failed to assess and develop an individualized care plan for Resident #71 with limited mobility having a trapeze bar, including lack of annual assessment and care plan for trapeze bar use.
Facility failed to consistently monitor, document, and evaluate the ongoing benefits of an increased dose of Seroquel for Resident #14, with missing Monthly Psychiatric Summary (MPS) notes and monitoring.
Report Facts
Undocumented nutritional supplement amounts: 102
Psychotropic medication dose increase: 150
Brief Interview for Mental Status (BIMS) score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged missing documentation of nutritional supplement consumption and lack of psychotropic medication monitoring |
| Registered Nurse | Registered Nurse | Interviewed regarding documentation of nutritional supplement consumption for Resident #47 |
| Registered Nurse/Unit Manager | RN/UM | Provided information about Resident #14's cognitive status and psychotropic medication monitoring |
| Licensed Practical Nurse | LPN | Reported behavior improvement and no hallucinations for Resident #14 |
| Occupational Therapist/Rehab Director | OT/RD | Provided information about trapeze bar assessment and care planning for Resident #71 |
| Certified Nursing Assistant | CNA | Reported observations about Resident #71's use of trapeze bar and functional ability |
| Administrator | Administrator | Spoke with surveyors regarding deficiencies and concerns |
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