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The next survey window likely opens around November 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 Complete Care At Wayne Hills Rehab & Resp Center during CMS and state inspections, most recent first.
A resident with functional quadriplegia, moderate cognitive impairment, and documented need for 2-person assist with repositioning experienced a fall from bed during care when only one CNA was turning the resident, resulting in the resident’s legs falling off the bed. The care plan identified fall risk but did not specify the resident’s risk level or required number of staff for repositioning, and there was no documentation of interventions implemented after the fall. In the days following, staff later observed bruising, pain behaviors, and swelling, but there was no evidence of ongoing monitoring for pain or injury or documentation of the origin of a right-hand bruise and swelling; hospital imaging ultimately showed bilateral femur fractures and a suspected finger fracture, which the facility’s investigation linked back to the earlier fall.
A resident with muscle weakness, functional quadriplegia, and moderate cognitive impairment developed swelling and bruising of the right hand that was added to the care plan but not reported to the NJDOH as an injury of unknown origin. A facility reportable event submitted days later did not address this hand injury, and the DON confirmed there was no documentation showing it had been reported, despite a facility abuse/neglect policy requiring timely reporting of all alleged violations to state authorities.
The facility failed to conduct thorough, separate investigations into two incidents involving a resident with muscle weakness, functional quadriplegia, and moderate cognitive impairment. During incontinent care, the resident’s legs slid off the bed while the upper body remained on the bed, and later the resident developed right hand swelling and bruising that was added to the care plan. Despite facility policy requiring prompt reporting and same-day, signed witness statements with an investigation initiated by the nursing supervisor, the DON acknowledged that no separate investigation was completed for the first incident and no investigation was conducted to determine how or when the right hand injury occurred.
A resident with severe cognitive impairment and total dependence on staff for eating did not receive the necessary assistance with breakfast, as evidenced by an untouched meal tray at the bedside. Staff failed to provide the required support despite the resident's documented needs and care plan interventions.
Two residents with significant cognitive and physical impairments did not consistently receive or have documented wound care as ordered by their physicians, as shown by multiple blank entries in the Treatment Administration Records for various wound treatments and assessments. The DON confirmed that nursing staff were responsible for implementing and documenting these orders, but the facility's own documentation policy was not followed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severely impaired cognition and a history of false accusations reported sexual abuse while hospitalized. The facility's DON and LNHA failed to report the allegation to the NJDOH, as required by state and federal regulations, because the report was not made directly to them and the resident was not in the facility at the time. This oversight violated the facility's policy on reporting and investigating abuse allegations.
A resident with severely impaired cognition reported an alleged sexual abuse incident to a hospital social worker, which was not investigated by the LTC facility staff. The DON and LNHA were informed of the allegation during a morning meeting but did not report it to the appropriate agencies, as required by the facility's policy. The social worker also did not investigate, assuming it was the responsibility of the DON and Administrator.
The facility failed to ensure that primary physicians signed monthly orders and wrote progress notes every other month for 10 residents over six months. Despite frequent visits by the physician and NP, records showed inconsistent signage and note-taking. Facility policies did not ensure compliance with regulations for physician visits every 60 days.
The facility failed to submit MDS assessments within the required timeframe for a resident, with delays noted in both Quarterly and Significant Change MDS submissions. A resident, who was cognitively intact and had a history of urinary tract infections, was involved. The Regional MDS Coordinator was consulted but did not provide further information.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in care management. One resident's bowel continence was incorrectly coded, and pain presence and fall history were not assessed. Another resident's bowel continence was initially not rated, and CNA documentation was inconsistent. These issues were identified through interviews and record reviews, revealing gaps in assessment and documentation processes.
A facility failed to accurately document a resident's bowel elimination status, despite the resident reporting regular bowel movements. Staff interviews revealed inconsistencies in documentation, with the CNA and RN/UM stating the resident had regular movements, while the MDSC/RN noted the resident was documented as always incontinent. The facility's policy emphasized the need for accurate records to ensure effective communication among the care team.
A resident with severe cognitive impairment and acute respiratory failure was observed receiving oxygen therapy incorrectly, as the nasal cannula was not positioned in the nostrils but on the cheek. The oxygen tubing lacked markings to indicate when it was applied, contrary to facility protocol. The Registered Nurse Unit Manager confirmed the oversight and adjusted the cannula, acknowledging the need for proper dating and regular changing of the equipment.
Failure to Implement Fall-Prevention Interventions and Post-Fall Assessment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement adequate fall-prevention interventions and to thoroughly assess and monitor a resident after a fall and subsequent signs of injury. The resident was admitted with multiple significant diagnoses, including acute respiratory failure, muscle weakness, schizoaffective disorder, seizures, and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A comprehensive nursing assessment documented that the resident’s mobility was very limited, that they were unable to make frequent or significant changes independently, and that they were dependent on others for ADLs. Progress notes prior to the incident documented that the resident required total care with two-person assist for repositioning, but the baseline care plan, while identifying a fall risk focus area, did not specify the resident’s fall risk level or the number of staff required to assist with repositioning in bed. On the date of the fall, the Facility Reportable Event (FRE) stated that while a CNA was providing care, the resident was squirming and holding the side rail while being turned in bed, and the resident’s lower legs fell off the bed while the torso remained on the bed. The CNA and an RN then repositioned the resident back to bed and assessed the resident. However, there was no documented evidence that the facility implemented any interventions following this fall to address the resident’s fall risk or to protect the resident from further injury. An employee statement from the CNA did not indicate that two staff assisted with repositioning during the care at the time of the incident, and in a subsequent interview, the RN confirmed that she did not assist the CNA with repositioning, only assessing the resident afterward and noting no pain. The RN did not provide information regarding follow-up interventions or the required level of care for the resident. In the days following the fall, the facility failed to adequately assess and monitor the resident for pain and injury. The FRE documented that an LPN later noticed bruising on the resident’s bilateral lower extremities, and other staff statements described the resident exhibiting signs of pain, flinching during assessment, and having bruising on both thighs and the lower back. The resident was then sent to the hospital, where imaging revealed acute fractures of the distal shafts of both femurs and a suspicious subtle fracture at the base of the proximal phalanx of the right third finger, associated with pain and bruising. The facility’s FRE did not address the right-hand swelling and bruise, and there was no documentation regarding the origin of the right-hand injury. The facility’s investigational summary concluded that the bilateral femur fractures identified later were the result of the earlier fall, but there was no evidence that the facility monitored the resident for pain and injury after the fall or implemented interventions on the date of the fall to prevent further injury, despite a policy stating that appropriate and immediate interventions and root cause analysis would be conducted for incidents and accidents.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) after swelling and bruising were identified on a resident’s right hand. The resident had diagnoses including muscle weakness and functional quadriplegia and a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. On 12/01/25, the resident’s care plan documented a focus area of swelling and bruising to the right hand, but there was no corresponding report of this injury to NJDOH as required for suspected abuse, neglect, or injury of unknown origin. A review of the facility’s Reportable Event submitted to NJDOH on 12/05/25 showed that it did not address the bruise and swelling on the resident’s right hand. During an interview on 1/29/26, the DON stated that the facility could not provide any documented evidence that the swelling and bruise identified on 12/01/25 had been reported to NJDOH. This failure occurred despite the facility’s Abuse, Neglect and Exploitation policy, revised 9/01/25, which required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified time frames, depending on whether abuse or serious bodily injury was involved.
Failure to Conduct Separate and Thorough Incident Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into two separate incidents involving one resident. The resident was admitted with diagnoses including muscle weakness and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A progress note dated 11/27/25 documented that during incontinent care, while the resident was being turned in bed, both lower extremities slid off the bed and touched the floor while the upper body remained on the side of the bed. A statement from the RN involved indicated the resident was not injured and did not exhibit signs of pain after this fall. The unit manager LPN stated that the facility’s process requires the assigned nurse to report incidents to the nursing supervisor, who is then expected to obtain, on the day of the incident, signed and dated witness statements from all staff involved and to start the investigation. The resident’s care plan included a focus area for right hand swelling and bruising, initiated on 12/01/25. However, the DON reported that there was no separate investigation conducted for the 11/27/25 incident apart from an investigation related to a later incident on 12/03/25. The DON also confirmed that the swelling and bruise identified on the resident’s right hand on 12/01/25 did not have a separate investigation to determine how or when the injury occurred. As a result, the facility did not follow its stated process for timely and complete incident investigation and failed to investigate the origin of the resident’s right hand injury, leading to the cited deficiency under NJAC 8:39-4(f).
Failure to Provide Required Assistance with Meals for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs), including eating, did not receive the necessary assistance with breakfast. The resident had diagnoses of functional quadriplegia, dementia, and severe protein calorie malnutrition, and was assessed as having severely impaired cognition with a BIMS score of 3 out of 15. The resident's care plan specified total dependence on two staff members for eating. Despite these documented needs, the resident's breakfast tray was found untouched at the bedside, indicating that staff did not provide the required assistance. Interviews revealed that the resident's representative observed the untouched breakfast tray and reported it to the Director of Social Services, who confirmed the tray had not been touched and that the resident required staff assistance to eat. The Director of Nursing stated that residents needing meal assistance were identified on the CNA assignment sheet and that CNAs, nursing staff, and the DON were responsible for providing this assistance. However, in this instance, the necessary support was not provided, resulting in the resident not receiving help with their meal as required by their care plan.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that two residents received wound care as ordered by their physicians, as evidenced by multiple missed or undocumented wound treatments. For the first resident, who was admitted with significant medical conditions including anoxic brain damage, severe contractures, impaired mobility, and incontinence, the care plan identified actual skin breakdown and multiple wounds, including pressure ulcers and arterial injuries. Review of the Treatment Administration Records (TARs) for September, October, and November revealed numerous blank entries where wound care orders were not documented as completed, including treatments for pressure ulcers, arterial ulcers, and skin tears, as well as required weekly skin assessments and offloading interventions. These omissions were confirmed through record review and interviews with the Director of Nursing (DON), who stated that facility nurses were responsible for implementing and documenting wound care orders received from an external wound care company. The second resident, admitted with diagnoses such as functional quadriplegia, dementia, and severe protein-calorie malnutrition, also had a care plan indicating actual skin breakdown, including multiple pressure ulcers and a trauma wound. Review of this resident's November TAR showed blank entries for several physician-ordered wound treatments, including the application of betadine, medihoney, and Triad Hydrophilic wound dressings to various wounds. These treatments were not documented as completed on the specified dates, and the DON confirmed that nursing staff were responsible for carrying out and documenting these orders. The facility's policy on documentation requires licensed staff and interdisciplinary team members to document all assessments, observations, and services provided in the resident's medical record. Despite this policy, the records for both residents showed repeated failures to document or complete ordered wound care treatments, as evidenced by the blank spaces in the TARs and confirmed by staff interviews.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to report an allegation of sexual abuse made by a resident to the New Jersey Department of Health as required. This deficiency was identified for one resident who had a history of false accusations towards staff and utilized nonverbal communication due to severely impaired cognition. The resident was admitted to the hospital with tracheostomy malfunction and respiratory distress, and during this time, the hospital social worker reported the alleged sexual abuse to the facility's Admissions Director via text. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed of the allegation during a morning meeting but did not report it to the appropriate authorities. The DON did not address the allegation because the social worker had not contacted her directly, and the resident was not in the facility at the time of the alleged incident. Both the DON and LNHA acknowledged their failure to report the allegation as per state and federal regulations and did not follow the facility's policy for reporting and investigating abuse allegations.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to investigate an alleged incident of sexual abuse reported by a resident to the New Jersey Department of Health. This deficiency was identified for one resident who had a history of false accusations and severely impaired cognition, as indicated by a BIMS score of 0 out of 15. The resident was admitted to the hospital with a tracheostomy malfunction and respiratory distress. During a morning meeting, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed by the Admissions Director about a text from a hospital social worker stating that the resident reported being sexually assaulted at the facility. However, the DON did not address the allegation because the social worker had not contacted her directly, and the resident was not in the facility at the time of the alleged incident. The facility's policy requires all allegations of abuse to be reported immediately to the Administrator and appropriate agencies, but this was not followed. The DON and LNHA acknowledged their failure to report the allegation within the required timeframe and did not adhere to the facility's policy for reporting and investigating abuse allegations. The social worker, who heard about the allegation during the morning meeting, did not investigate it, believing it was the responsibility of the Administrator and DON. The facility's policy outlines the need for immediate reporting and investigation of all allegations, but these procedures were not followed in this case.
Deficiency in Physician Order Signage and Progress Notes
Penalty
Summary
The facility failed to ensure that the primary physicians of residents signed and dated monthly physician orders and wrote progress notes every other month, alternating with the nurse practitioner. This deficiency was observed in 10 out of 20 residents reviewed over a six-month period. For several residents, the physician only electronically signed the monthly orders for March 2024, with no other orders signed in the previous months. Additionally, there were no monthly progress notes written by the physician during this period. The surveyor's review of the hybrid medical records revealed that the primary physicians did not consistently sign monthly orders or write progress notes for the residents. Interviews with facility staff indicated that the physician and nurse practitioner were present at the facility multiple times a week. However, the facility's policies and procedures for physician orders and visits, which were provided to the survey team, did not ensure compliance with state and federal regulations requiring physician visits at least every 60 days.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required timeframe for at least one resident. Specifically, the Quarterly Minimum Data Set (QMDS) for a resident was due to be transmitted to the Centers for Medicare and Medicaid Services (CMS) by April 4, 2024, but was not submitted until April 26, 2024. Additionally, a Significant Change MDS (SCMDS) for another resident was due by October 12, 2023, but was not submitted until October 21, 2023. These delays in submission were identified during a surveyor's review of the facility's records. The surveyor observed a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident's electronic medical record showed a history of urinary tract infections. The Regional MDS Coordinator was consulted regarding the late submissions but did not provide further information. The deficiency was noted as a failure to adhere to the timelines set forth by the CMS Resident Assessment Instrument (RAI) Manual, which requires assessments to be transmitted within 14 days of completion.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the management of their care. For Resident #63, the MDS was incorrectly coded as 'not rated' for bowel continence, despite the resident being incontinent and dependent on staff for care. The MDS Coordinator/Registered Nurse (MDSC/RN) acknowledged the error, noting that the MDS was modified to reflect the resident's incontinence. Additionally, the MDS failed to assess pain presence and fall history, despite documentation indicating no pain and no falls during the relevant period. The MDSC/RN admitted that the assessments were not addressed correctly, highlighting a lack of proper interviews and assessments. For Resident #85, the MDS initially failed to rate bowel continence, which was later corrected to indicate the resident was always incontinent. The resident's care plan confirmed total dependence on staff for incontinence care. However, the CNA documentation for a specific period was either blank or incorrectly coded, failing to reflect the resident's bowel movements accurately. Nursing progress notes did indicate incontinence, but the inconsistency in documentation contributed to the deficiency. These deficiencies were identified through interviews and record reviews conducted by surveyors. The MDSC/RN and other staff members were interviewed, revealing gaps in the assessment and documentation processes. The facility's failure to accurately code and assess the MDS for these residents resulted in a lack of proper care management, as evidenced by the discrepancies in the residents' records and the staff's acknowledgment of the errors.
Inaccurate Documentation of Bowel Elimination Status
Penalty
Summary
The facility failed to maintain the nursing professional standard of clinical practices by not accurately documenting the bowel elimination status of a resident who was reviewed for urinary catheter use. The resident, who was admitted with diagnoses including urinary tract infections, was observed to be cognitively intact and reported having a bowel movement at least once daily without issues. However, the facility's documentation, including the CNA Documentation Survey Report and Progress Notes, did not reflect the resident's bowel elimination status accurately during a specified period in March 2024. Interviews with facility staff, including a CNA, RN/UM, MDSC/RN, and DCS, revealed inconsistencies in the documentation and understanding of the resident's bowel movement schedule. The CNA and RN/UM indicated that the resident had regular bowel movements and would call for assistance when needed. However, the MDSC/RN noted that the resident was documented as always incontinent of bowel elimination, and the DCS highlighted the importance of accurate documentation. The facility's policy on Charting and Documentation emphasized the need for accurate records to facilitate communication among the interdisciplinary team.
Improper Oxygen Administration for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as observed by a surveyor. During an interview with the resident, it was noted that the nasal cannula, intended to deliver oxygen, was not positioned correctly in the resident's nostrils but was instead located on the cheek. Additionally, the oxygen supply tubing lacked any markings indicating when it was applied, which is against the facility's protocol. The resident, who was admitted with acute respiratory failure with hypoxia and essential hypertension, was assessed to have severe cognitive impairment, scoring 7 out of 15 on the Brief Interview for Mental Status (BIMS). Further observations confirmed the nasal cannula was still misplaced, and the Registered Nurse Unit Manager (RNUM) had to adjust it. The RNUM acknowledged the oversight and mentioned that oxygen tubing should be dated and changed weekly or sooner if needed. The facility's policy on oxygen administration specifies that the nasal cannula should be placed approximately one-half inch into the resident's nose. The deficiency was discussed with the facility's administrative team, including the Regional Clinical Registered Nurse, Regional Administrator, Director of Nursing, and Administrator.
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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) |
|---|---|---|---|---|
| Arbor Ridge Rehabilitation And Healthcare Center | 0.3 mi | — | 0 | 0 |
| Llanfair House Care & Rehabilitation Center | 1.1 mi | — | 0 | 0 |
| Oakland Rehabilitation And Healthcare Center | 1.6 mi | — | 0 | 0 |
| Phoenix Center For Rehabilitation And Pediatrics | 2 mi | — | 1 | 0 |
| Careone At Wayne | 2.5 mi | — | 8 | 0 |
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