Cycle 1
Health 2025-12-03 · Fire 2025-12-03
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wayne, NJ
Complete Care At Wayne Hills Rehab & Resp Center
2-star overall rating with 3-star inspections with $54,406 in total fines with 15 recent health deficiencies
130 Terhune Drive, Wayne, NJ
(973) 839-4500
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1969-09-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing
LPN hours / resident day
1.29
Licensed practical nurse staffing
Aide hours / resident day
1.39
Nurse aide staffing
Weekend hours
2.79
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.1
0.6 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
93.0%
4.5 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
97.2%
1.6 pts worse
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
2.4%
1.6 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.7% |
11.4%
2.7 pts better
|
11.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.2% |
4.6%
0.4 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
19.0%
7.6 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
13.5%
1 pts worse
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.3% |
9.8%
1.5 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
9.7%
2.6 pts worse
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
0.8%
1.4 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
15.9%
9.5 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 13.0% |
6.0%
7 pts worse
|
5.1%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.2% |
78.7%
4.5 pts worse
|
81.7%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
8.2%
0.4 pts worse
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.2%
2 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
80.1%
5.9 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
25.4%
4.3 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-24 · Fire 2024-05-24
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Cycle 3
Health 2022-02-23 · Fire 2022-02-23
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-07-07
F · Potential for more than minimal harm
2024-05-24
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
C · Minimal harm
2025-12-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-12-26
J · Immediate jeopardy
2025-07-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-25
D · Potential for more than minimal harm
2024-09-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-05-24
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-07-07
D · Potential for more than minimal harm
2024-05-24
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-07
D · Potential for more than minimal harm
2024-05-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-07
D · Potential for more than minimal harm
2024-05-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-07
D · Potential for more than minimal harm
2024-05-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-07
F · Potential for more than minimal harm
2023-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-25
E · Potential for more than minimal harm
2022-02-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-03-01
E · Potential for more than minimal harm
2022-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-01
D · Potential for more than minimal harm
2022-02-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-02-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-02-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-02-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-02-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-01
Penalties and ownership
What sits behind the stars
$54,406
2025-07-18
Fine
Fine · fine $54,406
Fine
Ownership
Lakeview Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Grella, William
Operational/Managerial Control · Individual
Lakeview Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Muller, Raphoel
Operational/Managerial Control · Individual
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Hershel
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Nearby options
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4-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
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Wayne, NJ
2-star overall rating with 2-star inspections with $72,775 in total fines with 10 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Oakland Rehabilitation And Healthcare Center
Oakland, NJ
2-star overall rating with 1-star inspections with Special Focus status with 17 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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