Complete Care at Wayne Hills Rehab & Resp Center

Inspectors wroteBased on observations, interview, and review of other pertinent documents on 6/11/26 and 6/12/26, it was determined that the facility failed to: a) ensure appropriate Enhanced Barrier Precautions (EBP, infection-control measures used in nursing homes to prevent the spread of multidrug-resistant organisms (MDROs)) were followed when Licensed Practical Nurse (LPN #1) was observed to not change gloves before performing closed tracheal suctioning (a sterile, self-contained device that allows healthcare providers to remove airway secretions without disconnecting the patient from a mechanical ventilator), a secondary high-contact task, and artificial airway, such as a tracheostomy), b) failed to ensure LPN #1 changed gloves after accessing a gastrostomy tube, a high-contact task, and before touching the privacy curtains and the window blinds in both Resident #4's and Resident #6's rooms, and [...]

Inspectors wroteComplaint #2687290 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 1/29/26, it was determined that the facility failed to a) implement adequate interventions to address the resident's risks for fall, and b) thoroughly assess and monitor a resident following a fall incident on 11/27/25, and after the identification of swelling and ecchymosis [bruise] on the resident's right hand on 12/01/25. According to Facility Reportable Event (FRE), a Licensed Practical Nurse (LPN #1) on the 11- 7 shift on 12/03/25, noticed bruising on the resident's bilateral lower extremities. According to an employee statement, Resident #1 was observed exhibiting signs of pain, and when staff assessed the resident on 12/03/25, the resident flinched like they were in pain. [...]

Inspectors wroteComplaint # 2687290 Based on interviews, medical record reviews, and review of other pertinent facility documents on 1/29/26, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH), an injury of unknown origin by not reporting a bruise and swelling on the resident's right hand the facility found on 12/1/2025. This deficient practice was identified for 1of 4 residents reviewed (Resident #1) A review of Resident #1's admission Record (AR) revealed that the resident was admitted to the facility with diagnoses that included but was not limited to muscle weakness and functional quadriplegia (unable to move arms and legs). [...]

Inspectors wroteComplaint #2687290Based on interviews, medical record reviews, and review of other pertinent facility documents on 1/29/26, it was determined that the facility failed to conduct thorough investigations into incidents on 11/27/25 and 12/1/25. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1). The evidence was as follows: A review of Resident #1's admission Record (AR) revealed that the resident was admitted to the facility with diagnoses that included but was not limited to muscle weakness and functional quadriplegia. A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool dated 11/28/25, revealed that Resident # 1 had a Brief Interview Mental Status (BIMS) score of 9 out of 15, which indicated the resident was moderately cognitively impaired. [...]

Inspectors wroteComplaint # 2624450, 2661339 Based on interview, record review, and review of pertinent facility documentation on 11/12/25, it was determined that the facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received the necessary assistance with breakfast in accordance with their assessed needs. This deficient practice was identified for 1 of 3 residents reviewed for ADLs (Resident #2). The evidence was as follows: A review of the admission Record (AR) revealed that Resident #2 was admitted to facility with diagnoses that include but were not limited to; functional quadriplegia, dementia, and severe protein calorie malnutrition. [...]

Inspectors wroteBased on interview, record review and, review of other pertinent facility documents on 11/12/25, it was determined that the facility failed to ensure that a resident received wound care as ordered by the physician. This deficient practice was identified for 2 of 2 residents reviewed for wound care (Resident #1 and Resident #2). The evidenced was as follows: 1. A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to; anoxic brain damage, stereotyped movement disorder, muscle spasm, and depressive disorder. A review Resident #1's quarterly Minimum Data Set (MDS) an assessment tool dated 9/4/25, revealed that the resident's cognition was severely impaired. A review of the Care Plan dated on 6/9/25, included a focus area that Resident #1 had actual skin breakdown; [...]

Inspectors wroteBased on observations, document review, interviews, and policy review, the facility failed to ensure cold storage areas were clean, the freezer temperature was within standards, expired foods were disposed of properly, the ice machine was cleaned, and the food thermometer was cleaned between use for one of one kitchen and one of two food pantries affecting 84 of 104 residents who consumed food in the facility. This failure had the potential to lead to foodborne illnesses and cross contamination.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to protect a resident's right to dignity while receiving medication through a gastrostomy tube (G-tube-a tube inserted into the stomach for nutrition and medication) for one (Resident (R) 108) of one resident observed for G-tube medications out of a total sample of 27. This failure placed residents at risk of a diminished quality of life and embarrassment.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide information on the risks and benefits of the use of a wander guard for one (Resident (R)10) of one resident reviewed for elopement in a total sample of 27. This failure placed the residents and/or representatives at risk of not being informed.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure beds and baseboard heaters were maintained in a safe manner for three of 27 residents (Resident (R) 10, R54, and R13) whose environments were reviewed. This failure had the potential to cause injury.

Inspectors wroteBased on record review, interview, facility document review, and policy review, the facility failed to provide a notice of transfer to the resident, the representative, and Ombudsman; failed to ensure notices contained information related to the appeals process; and/or failed to record the reason for discharge in a language that could be understood for two of four resident (Resident (R) 8 and R28) reviewed for discharge requirements out of a total sample of 27. These failures had the potential to cause confusion for residents and representatives trying to make informed decisions when residents were transferred to the hospital.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the accuracy of the Minimum Data Set (resident assessment) related to an antipsychotic medication for one of 27 residents (Resident (R) 75) reviewed creating an inaccurate assessment of the resident's psychological status.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop and implement a comprehensive care plan for three of 27 residents (Resident (R) 11, R8, and R65) reviewed. Specifically, the facility failed to develop an individualized activity care plan for R11 creating the potential for individual interests to not be identified; failed to develop an individualized care plan for R8 related to her seizure disorder creating the potential for staff to not respond as needed; and failed to develop an individualized care plan for R65's preference for daily showers creating the potential for showers to be missed.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure the Fall Care Plan was updated to include interventions to prevent falls after a resident had a fall with major injury for one (Resident (R) 13) of five residents reviewed for falls in a total sample of 27 residents. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to provide activities to meet the interests or needs of two of 27 residents (Resident (R) 11 and R8) reviewed. The failures created the potential for in-room visits to occur without the residents' individual interests or choice.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's room was free of accident hazards for one of 27 sampled residents (Resident (R)8). Specifically, the facility failed to respond timely to a water leak which reached electrical cords to the ventilator, bed, and enteral feeding pump of the resident. This failure had the potential to cause injury or equipment failure.

Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to ensure a physician order and consent was obtained for bed rail use for one of one resident (Resident (R) 65) reviewed for bed rails out of 27 sample residents. This failure had the potential to affect safety for all residents who had bed rails.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure medications were administered in accordance with infection control measures for one (Resident (R) 108) of six residents reviewed in a total sample of 27. This failure placed residents at risk of cross-contamination.

Inspectors wroteBased on observation, interview, and document review, the facility failed to post the daily staffing report. This deficient practice has the potential to affect all 104 residents and visitors by not accurately informing them of the available nursing staff to care for the residents.

Inspectors wroteComplaint #: NJ00183653 Based on observation, interviews, and review of pertinent facility documents on 07/14/2025, 07/15/2025, and 07/18/2025, it was determined that the facility failed to implement their abuse policy and procedure to ensure all residents were protected from abuse when a cognitively impaired resident (Resident #1) was discovered tied to their wheelchair by their roommate (Resident #3) on 01/15/2025, and the incident was not reported and Resident #1 remained with their roommate until 01/16/2025. This deficient practice was identified for 1 of 7 residents reviewed for abuse (Resident #1). A review of the Facility Reportable Event (FRE), dated 01/17/2025, revealed that Resident #1's Representative (RR #1) reported observing Resident #1 tied to their wheelchair on 01/15/2025. [...]

Inspectors wroteComplaint #: NJ00176749 Based on interviews and a review of the medical records and other facility documentation, it was determined that the facility staff failed to report an allegation of sexual abuse made by a resident (Resident #2) to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 4 residents (Resident #2) and was evidenced by the following: The surveyor reviewed Resident #2's medical record on 09/10/2024. The admission Record reflected the Resident #2 was admitted to the facility with medical diagnoses which included but not limited to: Type 2 Diabetes, Acute and Chronic Respiratory Failure, Morbid Obesity, Tracheostomy Status, Hypertension, Anxiety Disorder, Chronic Obstructive Pulmonary Disorder, and Other Seizures. [...]

Inspectors wroteComplaint #: NJ00176749 Survey Dates: 09/10/2024 Census: 85 Sample Size: 4 Based on interviews and a review of the medical records and other facility documentation, it was determined that the facility staff failed to investigate an alleged incident of sexual abuse made by a resident (Resident #2) to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 4 residents (Resident #2) and was evidenced by the following: The surveyor reviewed Resident #2's medical record on 09/10/2024. The admission Record reflected the Resident #2 was admitted to the facility with medical diagnoses which included but not limited to: Type 2 Diabetes, Acute and Chronic Respiratory Failure, Morbid Obesity, Tracheostomy Status, Hypertension, Anxiety Disorder, Chronic Obstructive Pulmonary Disorder, and Other Seizures. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to ensure that the resident's primary physicians a.) signed and dated monthly physician orders and b.) wrote physician progress notes every other month alternating with the nurse practitioner. The deficient practice was observed for 10 of 20 residents (Resident #38, 37, 45, 72, 74, 16, 41, 63, 1, and 78) reviewed and occurred over a 6-month period. The deficient practice was evidenced by the following: 1. A review of the hybrid medical record for Resident #38 revealed the physician electronically signed monthly physician orders for the month of March 2024. There were no other monthly physician orders signed within the past 6 months. Additionally, there were no monthly progress notes written by the physician in the previous 6 months. 2. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 1 of 20 residents (Residents #136). This deficient practice was evidenced by the following: On 05/14/24, at 9:41 AM, the surveyor observed Resident #63 lying in bed watching television. The resident was able to answer the surveyor's inquiry. Resident #63's electronic medical record (eMR) revealed the following information: [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, in accordance with the federal guidelines for 2 of 20 residents (Resident #63, and #85) reviewed for the accuracy of MDS coding. The deficient practice was evidenced by the following: 1. On 5/14/24, at 9:41 AM, the surveyor observed Resident #63 lying in bed watching television, able to answer the surveyor's inquiry. The resident stated that they had a bowel movement at least once daily and had no problem. Resident #63's electronic Medical Record (eMR) revealed the following information: According to the admission Record (an admission summary) (AR), Resident #63 was admitted to the facility with diagnoses that included but were not limited to urinary tract infections. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain the nursing professional standard of clinical practices by not accurately documenting the bowel elimination status of 1 of the 20 residents (Resident #63) who had been reviewed for urinary catheter. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that oxygen care and services were provided according to the standard of clinical practice in one (1) of (1) residents observed for respiratory care. The deficient practice was evidenced by the following: On 5/15/24 at 11:34 AM, the surveyor interviewed Resident #85. During the interview, the surveyor observed that the resident was receiving oxygen by a nasal cannula (a tube attached to an oxygen source that delivers oxygen to the resident via the nostrils). The surveyor observed that the nasal cannula was not positioned in the nostrils of the resident and was located to the left of the resident's nose, on the cheek. [...]

Inspectors wroteComplaint NJ # 167624 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to follow Centers for Disease Control (CDC) guidance and implement infection control practices to mitigate the spread of multiple multi-drug resistant organisms (MDROs) during an outbreak which began on 09/15/23. The facility failed to: a) implement infection control surveillance per facility policy for MDROs- Carbapenem-Resistant Acinetobacter Baumannii (CRAB-bacteria resistant to nearly all antibiotics and difficult to control and irradicate from the environment), and Candida Auris (CA- a dangerous fungus that can be difficult to identify and treat), and b) staff donned (put on) the required personal protective equipment (PPE) prior to entry to a resident room who was on Transmission Based Precautions. [...]

Inspectors wroteBased on observation interview and review of facility records, it was determined that the facility failed to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS). The deficient practice was observed on the automatic medication dispensing system located on the South Wing nursing office and evidenced by the following: On 2/18/22 at 10:05 AM, the surveyor reviewed the facility's DEA 222 forms and asked the Regional Clinical Specialist (RCS) a Registered nurse if he could provide the surveyor signed off logs showing that narcotics are being accounted for in the facility's AMDS. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow accepted standards of infection control to reduce the spread of infection as observed for 2 of 2 Licensed Practical Nurses (LPN #1 and LPN #2) and 3 of 3 Housekeepers (HK #1, HK #2, and HK #3). The deficient practice is evidenced by the following. 1. On 2/16/22 at 11:00 AM the surveyor observed LPN #1 perform a pressure ulcer treatment on Resident #42. The surveyor and LPN #1 reviewed the physician's order on the electronic record - cleanse sacral pressure ulcer with normal saline solution, pat dry, pack wound with calcium alginate and cover with a dry dressing daily and as needed if soiled, initiated 12/25/21. LPN #1 stated the resident had a stage 4 (full thickness) pressure ulcer on the sacrum. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of clinical practice by failing to document injection sites on the electronic Medication Administration Record (eMAR) for 1 of 18 residents (Resident #70) reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that oxygen therapy was administered to a resident in accordance with physician's orders. This was found with 2 of 6 residents reviewed, Resident #63 and Resident #61. The deficient practice was evidenced by the following: 1. On 2/11/22 at 11:00 AM, the surveyor observed Resident #63 walking from the bathroom to sit on bed. The surveyor observed Resident #63 putting on a tracheostomy collar over the tracheostomy (a surgical opening in the windpipe). The tracheostomy collar delivered the oxygen to the resident via the tracheostomy. The resident stated that he/she was encouraged to keep the oxygen on. The surveyor reviewed the electronic medical record (EMR) of Resident #63 which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to consistently assess a resident upon return from the dialysis center. The deficient practice was observed for 1 resident, #74, of 1 reviewed for dialysis and is evidenced by the following. On 2/11/22 at 1:08 PM, the surveyor observed the resident in bed with eyes closed. The resident was discharged from the facility on 2/14/22. On 2/15/22 at 9:54 AM, the surveyor interviewed the unit Licensed Practical Nurse (LPN). The LPN stated the pre dialysis resident assessment was documented on the top of the Nursing Facility/Dialysis Center Communication Record (a paper which travels with the resident to and from the dialysis clinic). She stated the post dialysis assessment is documented in the electronic medical record nursing progress notes. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 3 of 6 medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 10:20 AM, the surveyor inspected the East wing medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of Glucose testing solution and an opened Anoro Ellipta Inhaler that were not dated. The surveyor interviewed LPN #1 who stated that once a bottle of Glucose testing solution and an Anoro Ellipta inhaler are opened they should have been dated. On [DATE] at 11:15 AM, the surveyor inspected the East wing medication cart #2 in the presence of LPN #2. The surveyor observed an opened Humalog insulin vial that had an opened date of [DATE] and was expired. [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry steam table pans in a manner to prevent microbial growth and c.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 2/14/22 at 9:47 AM, in the presence of the Dietary Supervisor and Regional Food Service Director, the surveyor observed the following: 1. In the food preparation area, on a shelf over top of the convection ovens, the surveyor observed three full sized sheet pans which were stacked with water between them. 2. [...]