Inspection Reports for Complete Care At Wayne Hills Rehab & Resp Center

Complaint #2624450 and #2661339 were substantiated based on interviews, record reviews, and facility documentation indicating failure to provide necessary assistance with activities of daily living and wound care as ordered.

The facility failed to ensure that Resident #2 received assistance with breakfast as required by their care plan, and failed to provide ordered wound care treatments for Residents #1 and #2, with multiple treatment administration records showing blank entries indicating treatments were not completed as ordered.

Complaint #: NJ00183653. The complaint investigation found that on 01/15/2025, Resident #1 was tied to their wheelchair by Resident #3 and the incident was not reported by CNA #1. Resident #1 remained with Resident #3 until 01/16/2025. The facility was notified of the Immediate Jeopardy on 07/15/2025 and submitted a Removal Plan on 07/17/2025. The Immediate Jeopardy was verified resolved on 07/18/2025.

The facility failed to implement its abuse policy by not immediately reporting and investigating the incident where Resident #1 was tied to their wheelchair by Resident #3. This failure placed residents at risk and resulted in an Immediate Jeopardy situation that was later addressed by a Removal Plan and corrective actions.

Complaint NJ00176749 involved failure to report and investigate an alleged incident of abuse involving Resident #2. The facility staff did not report the incident to the New Jersey Department of Health as required and failed to investigate the allegation properly. The facility acknowledged the failure to follow policy and regulatory requirements.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to report alleged violations of abuse and failure to investigate such allegations timely and properly. The facility also failed to meet minimum staffing ratios for certified nurse aides on multiple day shifts prior to the survey.

Complaint #: NJ00176749. The complaint alleged failure to report and investigate sexual abuse by Resident #2. The allegation was substantiated by interviews and record reviews.

The facility failed to timely report and investigate an allegation of sexual abuse involving Resident #2. The Director of Nursing and Licensed Nursing Home Administrator acknowledged not following state and federal regulations or the facility's policy for reporting and investigating abuse allegations.

The facility was found deficient in timely submission and accurate coding of Minimum Data Set (MDS) assessments for residents, proper documentation of bowel elimination status, appropriate respiratory care including oxygen therapy management, and ensuring physicians sign monthly orders and write progress notes as required.

Complaint NJ # 167624 regarding failure to follow CDC infection control guidance and PPE use during an outbreak of Carbapenem-resistant Acinetobacter baumannii and Candida Auris.

The facility failed to implement proper infection control surveillance and PPE use, including staff not donning required PPE correctly before entering rooms with Transmission Based Precautions. The facility also lacked accurate infection surveillance tracking and documentation during the outbreak.

Complaint NJ #167624 regarding infection control failures during an MDRO outbreak was substantiated based on observations, interviews, and documentation review.

The facility failed to implement infection control surveillance for MDROs including Carbapenem-Resistant Acinetobacter Baumannii (CRAB) and Candida Auris, and staff failed to properly don required personal protective equipment (PPE) prior to entering resident rooms under Transmission Based Precautions. Multiple observations and interviews confirmed improper PPE use and lack of adequate surveillance documentation.

The facility was found not in substantial compliance with professional standards of care, medication administration, respiratory care, dialysis assessments, pharmacy services, medication labeling and storage, food safety, and infection prevention and control. Deficiencies were cited in multiple areas including failure to document medication sites, failure to follow physician orders for therapy, inadequate dialysis assessments, inaccurate controlled medication inventories, improper medication labeling and storage, unsanitary food handling, and breaches in infection control practices.

The facility was found deficient in multiple areas including failure to document injection sites for medications, inadequate respiratory care and oxygen therapy administration, inconsistent dialysis access site assessments, failure to maintain accurate controlled medication inventories, improper medication labeling and storage, unsafe food storage and sanitation practices, and breaches in infection prevention and control practices by nursing and housekeeping staff.

The facility was found deficient in accurately documenting nutritional supplement consumption for one resident, failing to assess and develop a care plan for a resident with limited mobility using a trapeze bar, and inconsistently monitoring and documenting the effects of increased doses of psychotropic medication for another resident. These deficiencies were associated with minimal harm or potential for actual harm and affected a few residents.