Inspection Reports for Wynwood Rehabilitation And Healthcare Center
1700 Wynwood Drive, NJ, 08077
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
105 residents
Based on a May 2025 inspection.
Census over time
Notice
Deficiencies: 0
Nov 19, 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, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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 the notice |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
May 1, 2025
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers. The survey was conducted on 4/30/2025 and 5/6/2025 to investigate staffing ratio compliance.
Findings
The facility was found to be out of compliance with New Jersey Administrative Code 8:39 regarding mandatory access to care due to failure to meet required staffing ratios on 5 of 14 days reviewed. No negative resident outcomes were identified, but the facility acknowledged the importance of meeting minimum staffing ratios and implemented corrective actions.
Complaint Details
Complaint numbers NJ175624, NJ179323, NJ181021, NJ181681, NJ1884963 were investigated. The facility was found to be deficient in CNA staffing for residents on 5 of 14 days, but no negative resident outcomes were identified. The facility is in substantial compliance based on this complaint visit.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 5 of 14-day shifts reviewed, specifically CNA staffing shortages on the day shift. |
Report Facts
Survey Census: 107
Survey Census: 105
Sample Size: 8
Days with staffing deficiency: 5
CNA staffing required: 13
CNA staffing actual: 8
CNA staffing actual: 10
CNA staffing actual: 11
CNA staffing actual: 12
Inspection Report
Re-Inspection
Census: 103
Capacity: 114
Deficiencies: 18
Jul 15, 2024
Visit Reason
Recertification Survey conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and follow-up on prior deficiencies.
Findings
The facility was found in Immediate Jeopardy for failure to ensure adequate supervision of a resident with a history of wandering into other resident rooms leading to abuse, failure to provide adequate supervision during smoking, failure to report and investigate alleged abuse, failure to complete timely assessments and care plans, inadequate staffing levels, medication management deficiencies, and life safety code violations. The facility implemented corrective actions including resident transfers, staff in-servicing, audits, and policy updates.
Complaint Details
Complaint numbers NJ167264, NJ165558, NJ170219 were investigated. Findings included failure to maintain minimum staffing, failure to report abuse, and failure to provide adequate supervision and care.
Severity Breakdown
SS=K: 1
SS=L: 2
SS=H: 1
SS=D: 5
SS=F: 3
SS=G: 1
SS=E: 3
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision of a resident with a history of wandering into other resident rooms leading to abuse and neglect. | SS=K |
| Failure to provide adequate and consistent supervision for residents assessed as requiring supervision during smoking, leading to unsafe smoking practices and potential fire hazards. | SS=L |
| Failure to report alleged abuse to the Department of Health as required and failure to conduct thorough investigations of abuse allegations. | SS=H |
| Failure to complete a Significant Change in Status Assessment within required timeframe for a resident electing hospice services. | SS=D |
| Failure to provide timely and appropriate activities of daily living care for dependent residents, including incontinence and nail care. | SS=F |
| Failure to implement interventions to prevent pressure ulcers, ensure comprehensive wound care documentation, and notify physicians of wound status changes. | SS=G |
| Failure to follow physician orders for application and removal of splints to maintain range of motion for a resident. | SS=D |
| Failure to provide adequate supervision and assistance devices to prevent accidents related to residents' smoking materials and wandering behaviors. | SS=L |
| Failure to maintain acceptable nutritional status and follow-up on resident goals and preferences regarding enteral feeding. | SS=D |
| Failure to ensure adequate indication and annual gradual dose reduction of psychotropic medications. | SS=D |
| Failure to provide pharmaceutical services ensuring accurate medication labeling, removal of expired supplies, and accountability of controlled substances. | SS=E |
| Failure to perform hand hygiene consistently during medication administration, risking spread of infection. | SS=D |
| Failure to provide stable, hard packed all-weather travel surface at one exit discharge door. | SS=D |
| Failure to provide continuous emergency lighting with two lamps at three exit discharge doors. | SS=D |
| Failure to inspect kitchen range-hood fire suppression system semi-annually as required by NFPA 96. | SS=E |
| Failure to ensure corridor doors resist passage of smoke with gaps exceeding code requirements. | SS=E |
| Failure to provide ashtrays of noncombustible material and metal containers with self-closing covers in the smoking area. | SS=D |
| Failure to label and identify emergency electrical panel circuit breakers. | SS=F |
Report Facts
Residents present: 103
Licensed capacity: 114
Deficient CNA staffing days: 28
Deficiency severity counts: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #84 | Resident with history of wandering and abuse incidents | |
| Resident #94 | Resident reporting abuse by Resident #84 | |
| Resident #29 | Resident requiring supervision during smoking, involved in unsafe smoking practices | |
| Resident #150 | Resident with pressure ulcer and wound care deficiencies | |
| Resident #71 | Resident with splint application deficiencies | |
| Resident #27 | Resident reporting inadequate incontinence care | |
| Resident #30 | Resident with inadequate incontinence care | |
| Resident #37 | Resident with inadequate incontinence care | |
| Resident #41 | Resident with inadequate incontinence care | |
| Resident #95 | Resident with inadequate incontinence care | |
| Resident #62 | Resident receiving psychotropic medication without adequate dose reduction | |
| Resident #81 | Resident with unreported injury and incomplete investigation | |
| Resident #87 | Resident with unreported injury and incomplete investigation |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 4
Jun 27, 2023
Visit Reason
Complaint survey conducted due to complaint NJ00165109 to investigate alleged deficiencies in care and services.
Findings
The facility was found not in substantial compliance with professional standards of care, medication administration, pharmacy services, and resident record documentation. Deficiencies included failure to follow physician orders for medication administration, failure to ensure timely documentation of medication administration, and failure to notify physicians of changes in resident condition.
Complaint Details
Complaint #: NJ00165109. The facility was not in substantial compliance based on this complaint survey.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide care and services according to acceptable standards of clinical nursing practice including following physician's orders for PEG-tube flushes and medication dosage during medication administration. | SS=D |
| Failure to ensure timely documentation of medication administration for 4 residents. | SS=E |
| Failure to ensure notification to a resident's Medical Doctor of a change in condition was documented in the resident's medical record. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey. | — |
Report Facts
Census: 102
Sample Size: 5
Deficient CNA staffing days: 14
Required CNA staffing: 13
Actual CNA staffing: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and documentation findings. |
| LPN #2 | Licensed Practical Nurse | Observed administering medications including insulin to Resident #4. |
| LPN #3 | Licensed Practical Nurse | Observed administering medications to Resident #2 with medication dosage errors. |
| RN #1 | Registered Nurse | Interviewed regarding medication administration practices and standards. |
| Director of Nursing | Director of Nursing | Provided statements on medication administration expectations and monitoring. |
| Medical Director | Medical Director | Interviewed regarding notification of resident condition changes. |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Interviewed regarding notification and documentation of resident condition changes. |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Interviewed regarding medication administration expectations. |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing regulations and recruitment efforts. |
Inspection Report
Follow-Up
Census: 102
Deficiencies: 1
Nov 10, 2022
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing requirements and to follow up on previously identified deficiencies related to minimum direct care staff-to-resident ratios.
Findings
The facility was found deficient in maintaining the required minimum direct care staff-to-resident ratios on 14 of 14 day shifts reviewed, with CNA staffing consistently below the mandated levels. The facility implemented corrective actions including in-servicing the Staffing Coordinator, utilizing staffing agencies, and conducting wage analyses to improve recruitment and retention.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
Report Facts
CNA staffing deficiency days: 14
Residents on day shifts: 102
Required CNAs: 13
Actual CNAs: 7
Inspection Report
Life Safety
Census: 105
Capacity: 114
Deficiencies: 10
Nov 9, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/9/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including means of egress force, exit signage, hazardous area enclosures, sprinkler system maintenance, portable fire extinguisher installation, corridor door integrity, smoke barrier penetrations and doors, smoking regulations, and electrical junction box covers. Deficiencies had the potential to affect varying numbers of residents, up to all 105 residents in some cases.
Severity Breakdown
SS=E: 6
SS=F: 4
Deficiencies (10)
| Description | Severity |
|---|---|
| Force required to open exit door exceeded 30 lbf, and exterior gate did not swing in direction of egress. | SS=E |
| Directional exit signs missing at North and South nurse stations. | SS=F |
| Door to storage room (Beauty Shop) not self-closing or automatic closing. | SS=E |
| Deficiencies or impairments found during sprinkler system inspection and maintenance were not corrected. | SS=F |
| Portable fire extinguisher in kitchen not securely installed on hanger. | SS=E |
| Corridor doors failed to latch and had excessive gaps allowing smoke passage. | SS=F |
| Penetrations in smoke barrier in attic were unsealed, allowing smoke transfer. | SS=E |
| Smoke barrier doors had a 3/4 inch gap between doors when closed, not providing effective smoke barrier. | SS=E |
| Smoking area lacked ashtrays of noncombustible material and metal container with self-closing cover device. | SS=E |
| Three electrical junction boxes in attic were open without covers. | SS=F |
Report Facts
Residents potentially affected: 32
Residents potentially affected: 105
Residents potentially affected: 16
Residents potentially affected: 105
Residents potentially affected: 18
Residents potentially affected: 105
Residents potentially affected: 53
Residents potentially affected: 52
Residents potentially affected: 17
Residents potentially affected: 105
Current census: 105
Total licensed capacity: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed deficiencies and implemented corrective actions for multiple findings including door force, exit signage, sprinkler system, fire extinguisher installation, corridor doors, smoke barriers, smoking area, and electrical junction boxes. | |
| Administrator | Provided education to maintenance staff on inspection procedures and compliance with NFPA 101. | |
| Director of Maintenance | Confirmed observations related to corridor doors and fire extinguisher installation. |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Mar 21, 2022
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ151951 and NJ152634.
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 #: NJ151951 and NJ152634. The facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Sep 30, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146833, NJ147678, and NJ147541 regarding staffing ratios and compliance with New Jersey Administrative Code 8:39 for licensure of long-term care facilities.
Findings
The facility failed to maintain the mandated direct care staff-to-resident ratios for 48 out of 66 shifts reviewed, potentially affecting all residents. The facility was not in substantial compliance with staffing requirements as per New Jersey State Law effective 02/01/2021.
Complaint Details
Complaint Intake NJ146833 found the facility failed to maintain required direct care staff-to-resident ratios. The facility was not in substantial compliance with New Jersey Administrative Code 8:39 standards.
Deficiencies (1)
| Description |
|---|
| Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law for 48 out of 66 shifts reviewed. |
Report Facts
Shifts reviewed: 66
Shifts with staffing deficiencies: 48
Census: 105
Staffing ratios: 1
Staffing ratios: 1
Staffing ratios: 1
Staffing counts: 9
Staffing counts: 6
Staffing counts: 7
Staffing counts: 7
Staffing counts: 12
Staffing counts: 8
Staffing counts: 7
Staffing counts: 7
Staffing counts: 7
Staffing counts: 7
Staffing counts: 8
Staffing counts: 7
Staffing counts: 7
Staffing counts: 7
Staffing counts: 8
Staffing counts: 7
Staffing counts: 8
Staffing counts: 7
Staffing counts: 8
Staffing counts: 6
Staffing counts: 9
Staffing counts: 9
Staffing counts: 6
Staffing counts: 7
Staffing counts: 7
Staffing counts: 7
Staffing counts: 7
Staffing counts: 9
Staffing counts: 7
Staffing counts: 7
Staffing counts: 8
Staffing counts: 9
Staffing counts: 7
Staffing counts: 8
Staffing counts: 9
Staffing counts: 9
Staffing counts: 9
Staffing counts: 9
Staffing counts: 9
Staffing counts: 9
Staffing counts: 8
Staffing counts: 9
Staffing counts: 11
Staffing counts: 12
Staffing counts: 11
Staffing counts: 11
Staffing counts: 12
Staffing counts: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding staffing ratios and efforts to hire new staff | |
| Director of Nursing | Interviewed regarding staffing ratios and efforts to hire new staff |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Jul 10, 2021
Visit Reason
The inspection was conducted based on complaint NJ146553 to investigate allegations related to food temperature and hygiene practices in the facility.
Findings
The facility was found not in substantial compliance due to failure to serve hot and cold foods at acceptable temperatures and failure to follow food preparation and hygiene policies, including staff not wearing hairnets in the kitchen.
Complaint Details
Complaint NJ146553 was substantiated with findings that the facility failed to maintain proper food temperatures and hygiene practices during the complaint investigation visit on 7/10/2021.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to serve hot and cold foods at acceptable temperatures as evidenced by test trays with food items not within correct temperature ranges. | SS=D |
| Failure to perform appropriate hygiene protocol by not wearing hairnets in the kitchen, risking contamination. | SS=D |
Report Facts
Census: 97
Sample Size: 3
Food temperature measurements: 123
Food temperature measurements: 126
Food temperature measurements: 64.4
Food temperature measurements: 53.5
Food temperature measurements: 57.7
Food temperature measurements: 59.3
Food temperature measurements: 121
Food temperature measurements: 133
Food temperature measurements: 128
Food temperature measurements: 73
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Jun 4, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers listed in the report.
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 numbers NJ141795, NJ141600, NJ141468, NJ141315, NJ140918, NJ140894, NJ140317, and NJ139742 were investigated and the facility was found compliant.
Report Facts
Sample Size: 26
Inspection Report
Routine
Census: 100
Deficiencies: 0
Nov 17, 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 and recommended COVID-19 practices.
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: 6
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