Complete Care at Wayne Hills Rehab & Resp Center

In the surveyor’s words

From the most serious findings on record at Complete Care at Wayne Hills Rehab & Resp Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 18, 2025

  Complaint #: 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. […]

• Actual harm, isolatedF689Jan 29, 2026

  Complaint #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. […]

• No harm, potential for more than minimal, widespreadF880Sep 26, 2023

  Complaint 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… […]

• No harm, potential for more than minimal, patternF812Dec 3, 2025

  Based 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.Findings include: During an observation on 11/30/25 at 8:00 AM, alongside the Dietary Manager (DM), the upright meat cooler had a container of raw meat on an upper shelf- leaking blood throughout, on the right side of the rack. The left side of the white rack had dried pink liquid. […]

• No harm, potential for more than minimal, patternF711May 24, 2024

  Based 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. […]