Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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 keep cold storage areas clean, maintain proper freezer temperatures, dispose of expired foods, clean the ice machine, and sanitize the food thermometer between uses. Observations found leaking raw meat in a cooler, an ice cream freezer at 20 degrees F with soft product, dirty and rusty freezer racks, expired food items in a pantry refrigerator and freezer, a dirty ice machine with no November cleaning entry, and a DA using a thermometer without sanitizing it between temperature checks.
A resident with cerebral palsy, respiratory failure, and severe cognitive impairment was observed receiving morning meds via G-tube while an RN entered the room without closing the door or pulling the curtain. The resident was left uncovered in bed, the gown was lifted to expose the abdomen, G-tube, and brief, and the meds were given without privacy. The RN and DON both acknowledged the privacy lapse as a dignity issue.
A resident with schizoaffective disorder and dementia was identified as an elopement risk and had a wander guard on the right ankle, but the EMR did not show documentation that the resident or representative was informed of the risks and benefits of the device. The MDS showed severe cognitive impairment with delusions and use of a wander/elopement alarm, and the DON and ADON confirmed there was no documented information provided to the representative.
Unsafe Beds and Heating Element Observed in Resident Rooms: Two residents with dementia and severe cognitive impairment were observed with beds that had exposed rough plywood and peeled veneer with sharp edges. An LPN, the DON, the Maintenance Director, and a UM confirmed the beds were unsafe and needed replacement. A third resident was observed with a baseboard heating element pulled away from the wall while actively producing heat, with peeling metal covering and sharp edges; the resident said it had been that way since moving into the room, and the UM confirmed it was a safety hazard.
A facility failed to provide a transfer notice to a resident, the resident's representative, and the Ombudsman after the resident was sent to the hospital following a fall with forehead injuries. For another resident transferred to the ER for hypotension and AMS, the transfer notice did not include required appeal contact information and used medical terms that an LPN confirmed were not understandable to the resident representative. Both residents were severely cognitively impaired, and the facility policy required notices to include appeal rights and be written in a language and manner the resident and representative could understand.
Inaccurate MDS coding for antipsychotic medication. A resident with dementia and schizophrenia was prescribed quetiapine and received it as ordered, but the quarterly MDS did not code any antipsychotic use. The DCR, who completed the assessment, confirmed the medication should have been included because the resident was taking it.
A facility failed to develop and implement complete, individualized care plans for three residents. One resident with anoxic brain injury and no verbal communication had only generic activity visits, with no family input obtained about prior interests. Another resident with seizures and severe cognitive impairment had no seizure care plan despite a history of seizure disorder and Keppra use. A third resident with hemiplegia/hemiparesis had a care plan for daily total bed baths, but documentation showed repeated NA entries and the resident reported not receiving daily baths.
A resident with schizoaffective disorder and ataxic gait sustained a fall with a left radius fracture, but the Fall Care Plan was not updated to include that major injury or related interventions. The care plan listed prior falls and fall risk factors, and the UM confirmed the fracture-related fall should have been added as a Problem/Focus; a separate Pain Care Plan was completed for the fractured wrist.
Failure to provide individualized activities for two residents. One resident with anoxic brain damage was non-verbal and received routine room visits coded as not actively involved, while staff had not contacted family to learn prior interests and did not document responses to picture or sensory activities. Another resident with severe cognitive impairment and ventilator dependence had a care plan for TV, music, or visits, but the record did not show family input on preferences or what occurred during room visits.
Water from a bathroom sink overflowed into a resident's room and reached electrical cords for a ventilator, bed, and enteral feeding pump. The resident was severely cognitively impaired, used ventilator support, and had a tube feeding. Staff observed water under the bed and near the cords while an LPN tried to reach maintenance, and the MD later found a hose had come off a valve on the back of the sink.
A resident with hemiplegia and hemiparesis, and moderate cognitive impairment per BIMS, was observed with bilateral bed rails used for mobility. EMR review found no physician order, no care plan, and no informed consent for the bed rails. The Rehab Director said bed rails were used for residents at fall risk, and the DON acknowledged there were no orders or consents in place for the resident.
Medication administration was not carried out in accordance with infection control measures for a resident who was admitted with cerebral palsy, respiratory failure, and ventilator dependence. An RN brought four cups of meds into the room for G-tube administration and placed them on an overbed table without using a barrier or cleaning the surface first. The RN acknowledged the omission, and the DON stated that a disposable barrier should have been used.
The facility failed to post the nurse staffing report daily. The staffing report in the lobby was visible to the public but was outdated, and the DON and staffing coordinator both stated that weekend postings were not done. The facility policy stated that the Nurse Staffing Sheet would be posted on a daily basis.
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.
Food Storage, Ice Machine, and Thermometer Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure cold storage areas were clean, freezer temperatures were within standards, expired foods were disposed of properly, the ice machine was cleaned, and the food thermometer was cleaned between uses. During observation of the kitchen, the upright meat cooler contained a container of raw meat on an upper shelf that was leaking blood throughout the rack, with dried pink liquid on the left side of the white rack. The Dietary Manager stated it should have been cleaned right away and confirmed the meat should not have been leaking like that. The upright ice cream freezer was observed at 20 degrees F with ice cream containers soft and not fully frozen, while the three-door upright freezer across from it had thermometers reading 8 degrees F and 12 degrees F and the food inside was fully frozen. The walk-in freezer had dirty, rusty racks throughout, and the Dietary Manager stated the rust had been there a while and the racks should have been cleaned weekly.
Failure to Maintain Resident Dignity During G-Tube Medication Administration
Penalty
Summary
The facility failed to protect a resident’s right to dignity while administering medications through a G-tube for one resident who was admitted with cerebral palsy, respiratory failure, and dependence on ventilator status. The quarterly MDS indicated the resident could not be understood and was assessed as severely cognitively impaired. During an observation, an RN prepared the resident’s morning medications for G-tube administration and entered the room without shutting the door or pulling the curtain. The resident was lying in bed wearing a hospital gown, with no sheet or blanket covering the body. The RN lifted the gown, exposing the abdomen, G-tube, and brief, and administered the medications without closing the door or curtain. The RN stated she should have pulled the curtain or shut the door, and the DON stated that the action was a dignity issue.
Failure to Inform Resident or Representative About Wander Guard
Penalty
Summary
The facility failed to provide information on the risks and benefits of using a wander guard for one resident who was identified as an elopement risk. The resident was admitted with diagnoses that included schizoaffective disorder and dementia, and the care plan identified the resident as an elopement risk/wanderer with periods of impaired safety awareness. The care plan also documented that a wander guard was in place on the right ankle. Review of the EMR did not show documentation that the resident or the resident’s representative were informed of the risks and benefits of the wander guard. The annual MDS showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and noted delusions and use of a wander/elopement alarm. During interviews, the DON stated the resident had not eloped in the last year, and the ADON stated there was no information provided to the representative on the risks and benefits of the wander guard.
Unsafe Beds and Heating Element Observed in Resident Rooms
Penalty
Summary
The facility failed to ensure beds were maintained in a safe manner for two residents whose rooms were observed. R10, who was admitted with dementia and had a BIMS score of 7 out of 15 indicating severe cognitive impairment, was observed with a bed footboard and headboard that had exposed rough plywood and peeled veneer with sharp edges. R54, who was admitted with dementia and had a BIMS score of 5 out of 15 indicating severe cognitive impairment, was also observed with a bed footboard and headboard that had exposed rough plywood and peeled veneer with sharp edges. During the observation of R54's bed, an LPN confirmed the veneer was peeling and that the edges were sharp. The DON, Maintenance Director, and UM also observed the bed and confirmed it needed to be replaced right away. The facility also failed to maintain a baseboard heating element in a safe manner for R13, who was admitted with mild dementia with agitation and had a BIMS score of 14 out of 15. The heating element was observed pulled away from the wall while actively putting out heat, and its gray metal covering was peeling away and creating significant sharp edges. R13 stated it had been like that since moving into the room, and the UM confirmed it was a safety hazard.
Transfer Notices Missing Required Appeal Information
Penalty
Summary
The facility failed to provide a notice of transfer to the resident, the resident's representative, and the Ombudsman for one resident who was transferred to the hospital after being found on the floor next to the lower position bed with superficial lacerations on the forehead and a 2.5 cm abrasion on the right forehead. The resident's record showed diagnoses including dependence on respirator (ventilator) status, type 2 diabetes mellitus, and acute and chronic respiratory failure, and the quarterly MDS indicated the resident was severely cognitively impaired. Review of the EMR and the facility's Transfers binder found no documentation that the transfer notice was provided to the resident, the representative, or the Ombudsman. Staff interviews confirmed the notice should have been completed and that no notice was found for the resident. The facility also failed to ensure a transfer notice contained information related to the appeals process and was written in language that could be understood for another resident transferred to the emergency room for hypotension and altered mental status. That resident's record showed diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and tracheostomy status, and the quarterly MDS indicated severe cognitive impairment. The notice of transfer listed the reason for transfer as hypotension and AMS, but it did not include the name or contact information of an entity the resident representative could contact to appeal the discharge decision. The notice also used medical terminology that the LPN confirmed was not in language the resident representative would understand. The facility policy required transfer/discharge notices to be provided in a language and manner the resident and representative could understand and to include appeal rights and state entity contact information.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set for one resident, R75, related to antipsychotic medication use. R75 was admitted and readmitted with diagnoses that included dementia and schizophrenia. Physician orders showed quetiapine fumarate 50 mg by mouth twice a day for schizophrenia was started on 09/16/25, and the MAR showed the resident received the medication twice daily as prescribed during October 2025. The MAR for November 2025 showed R75 continued to receive the antipsychotic twice daily until hospitalization on 11/20/25, and after returning to the facility on 11/24/25 the medication was reduced to once daily. However, the quarterly MDS with an ARD of 11/06/25 did not identify the resident as taking any antipsychotic medication. During interview, the Director of Clinical Reimbursement, who completed the MDS, confirmed the antipsychotic should have been coded because R75 was taking the medication.
Incomplete and Unimplemented Care Plans for Activities, Seizures, and Bathing
Penalty
Summary
The facility failed to develop an individualized activity care plan for a resident with anoxic brain damage, anxiety disorder, and major depressive disorder who was unable to complete the BIMS and could not communicate verbally. The revised care plan stated that recreation would visit daily for social dignity and stimulation and maintain eye contact if possible, and activity records showed room visits every morning and afternoon coded as not actively involved. During observations, the resident was in bed in his room and could track with his eyes but could not consistently blink yes or no when asked. The Activity Director confirmed she created the activity care plans and described general room visits, but stated no one had been contacted to obtain information about the resident’s interests before his anoxic brain injury, despite active involvement from his mother and brother. The facility also failed to develop a care plan for a resident with dependence on respirator status and seizures. The resident’s record included a history and physical noting seizures and continuation of Keppra, and the quarterly MDS showed severe cognitive impairment. Review of the care plan found no plan of care for seizures. During interview, the ADON confirmed that the resident did not have a seizure care plan and stated that one should have been in place. In addition, the facility failed to implement the documented bathing plan for a resident with hemiplegia and hemiparesis affecting the left dominant side. The care plan identified total care for ADLs, including a total bed bath every day, but the November documentation survey showed multiple days marked as NA for shower/bathing/personal care and no showers or baths listed as completed according to the care plan. The resident stated he was not getting daily baths. A CNA stated the bathing schedule was Mondays and Wednesdays, while the DON stated she knew the care plan listed daily baths and that audits had been done to ensure documentation was completed, but documentation accuracy had not been checked.
Fall Care Plan Not Updated After Major Injury
Penalty
Summary
The facility failed to ensure the Fall Care Plan was updated to include interventions after a resident sustained a fall with major injury. R13 was admitted with diagnoses including schizoaffective disorder and ataxic gait, and the medical diagnosis list showed a displaced fracture of the head of the left radius with subsequent encounter for closed fracture with routine healing. A significant change MDS dated 09/25/25 showed a BIMS score of 15 out of 15, indicating R13 was cognitively intact, and also documented one fall with no injury, one fall with injury, and one fall with major injury since the prior assessment. Review of the Fall Care Plan revised 10/30/25 showed the resident was identified as at risk for falls related to psychoactive drug use and antihypertensive medication, and it listed prior falls on 06/13/25, 08/14/25, and 10/30/25, but it did not document the fall with major injury or updated interventions after the fracture. The Pain Care Plan revised 09/11/25 addressed pain related to the left wrist status post fall. During interview, the Unit Manager stated she was not that good at care plans but had completed a Pain Care Plan for the fractured wrist, and confirmed the 09/11/25 fall with fracture should have been listed as a Problem/Focus on the care plan. The facility policy required a comprehensive person-centered care plan for each resident that included all services identified in the comprehensive assessment.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide activities that met the interests or needs of two residents, including one resident with anoxic brain damage, anxiety disorder, and major depressive disorder who was unable to complete the BIMS and was non-verbal. The resident’s care plan directed recreation to visit daily for social dignity and stimulation and to maintain eye contact if possible. Activity participation records showed room visits every morning and afternoon, but each was coded as not actively involved. During observations, the resident was in bed in his room, unable to communicate verbally, and no radio or television was observed at his bedside; only the roommate’s television was on. The Activity Director stated that room visits consisted of greeting the resident, stating the date, weather, and holiday, placing a decoration on the wall if applicable, and leaving a facility newspaper. She also stated that pictures, sensory stimulation, or the resident’s television could be used, but no one had contacted the resident’s family to learn what he enjoyed before his injury, despite active involvement from his mother and brother. An activity assistant confirmed he provided picture viewing and smell-and-tell activities but did not document the resident’s reactions, did not contact family for prior interests, and did not provide music. A second resident, who was severely cognitively impaired and dependent on a respirator, had a care plan calling for TV, music, or visits to assist with socialization and dignity, but the record contained no documentation that family had been asked about preferred TV shows or music, and the activity calendar only showed room visits with no documentation of what occurred during them.
Water Leak Reached Electrical Cords in Resident Room
Penalty
Summary
The facility failed to ensure a resident's room was free of accident hazards when water from the back of the bathroom sink spilled over into a trash can and then into the resident's room, reaching electrical cords for the ventilator, bed, and enteral feeding pump. The resident was admitted with dependence on respirator (ventilator) status and acute and chronic respiratory failure, and the quarterly MDS showed the resident was severely cognitively impaired, used ventilator assistance for breathing, and had a tube feeding. During observation, water was seen on the floor under the bathroom area and flowing underneath the resident's bed near the window where the electrical cords were lying. Nursing staff were notified, and the LPN assessed the situation and attempted to reach maintenance. The water continued running from the sink and overspilling into the trash can until the Maintenance Director arrived and identified a valve on the back of the sink where a hose had come off. The Maintenance Director confirmed the water was under the bed and the electrical cords to the ventilator, bed, and feeding pump were laying in the puddled water. The DON stated the expectation was for maintenance to come immediately to stop the water from running into the resident's room and for nursing staff to ensure the resident was safe.
Bed rails used without physician order or consent
Penalty
Summary
The facility failed to ensure a physician order and informed consent were obtained for bed rail use for one resident. The resident had been admitted with diagnoses including hemiplegia and hemiparesis affecting the left dominant side. The admission nursing comprehensive assessment documented that the resident was assessed for bed rail usage, including proper fit, no gaps between the rails and mattress, and alternatives attempted. The annual MDS showed a BIMS score of 11 out of 15, indicating the resident was moderately cognitively impaired. Review of the EMR showed no orders for bed rails and no care plans related to bed rails, and there were no consents in place for bed rails. During observation, the resident was seen with bilateral bed rails used for mobility. The Rehab Director stated bed rails were used for residents at fall risk and Enabler bars were used for residents who could assist with rolling themselves. The DON acknowledged that the resident had Enabler bars and that there were no orders or consents in place for the resident prior to that date. The facility policy stated informed consent must be obtained after alternatives have been attempted, and then a physician's order must be obtained for bed rail use.
Medication Administration Infection Control Lapse
Penalty
Summary
Medication administration was not performed in accordance with infection control measures for one resident who was admitted with cerebral palsy, respiratory failure, and ventilator dependence. During an observation, an RN entered the resident’s room with medications prepared in four separate medication cups for administration through a G-tube and placed the cups on an overbed table without first using a barrier or cleaning the table. When questioned, the RN acknowledged that no barrier was placed and the table was not cleaned before the medication pass. The DON was informed of the observation and stated that a disposable barrier should have been used because barriers are kept in the cart. The facility policy titled Medication Administration states that medications are to be administered in a manner to prevent contamination or infection.
Failure to Post Daily Nurse Staffing Report
Penalty
Summary
The facility failed to post the daily nurse staffing report on a daily basis. During an observation on 11/30/25 at 8:00 AM, the New Jersey Department of Health Nursing Home Resident Care Staffing Report was found on a table in the lobby where it was visible to the public, but the posting date on the report was 11/28/25, and the next report behind it was dated 11/25/25. During interviews, the DON stated that the staffing posting was not done on weekends and that the staffing coordinator was responsible for placing the posting in the lobby when she worked. The staffing coordinator stated that she completed the postings Monday through Friday and that they were not done on weekends, although she had the report on her computer and could send it over. Review of the facility policy titled Nurse Staff Posting Information, dated 03/06/25, indicated that the Nurse Staffing Sheet would be posted on a daily basis.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,220 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Complete Care At Wayne Hills Rehab & Resp Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.