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
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.39
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
2.43
CMS adjusted total nurse staffing hours
Case-mix index
1.80
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,026
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.46
Baseline 18.58% · Performance 18.90% · Measure score 5.46 · Achievement 5.46 · Improvement 0
Healthcare-associated infections
0
Baseline 8.34% · Performance 10.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.04
Baseline 2.62 hours · Performance 3.11 hours · Measure score 1.04 · Achievement 0 · Improvement 1.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 14.29% · Lower 95% interval 7.32% |
| Discharge to community | 41.46% |
50.57%
9.1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 24.05% · Lower 95% interval 31.64% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 86 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 15 · Denominator 27 |
| Discharge mobility score | 51.85% |
50.94%
0.9 pts better
|
Numerator 14 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 8.14% |
2.29%
5.9 pts worse
|
Numerator 7 · Denominator 86 · Adjusted rate 4.59% |
| Healthcare-associated infections requiring hospitalization | 10.83% |
7.12%
3.7 pts worse
|
Worse than the National Rate · Eligible stays 55 · Observed rate 29.09% · Lower 95% interval 7.46% |
| Staff COVID-19 vaccination coverage | 1.36% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 147 |
| Staff flu vaccination coverage | 95.77% |
42%
53.8 pts better
|
Numerator 136 · Denominator 142 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 15 · Denominator 27 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 56 · Denominator 56 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10.42% |
25.2%
14.8 pts worse
|
Numerator 5 · Denominator 48 |
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 · Adjusted 2.3 · Observed 3.9 · Expected 3.3 · Used in QM five-star |
| 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 · Adjusted 1.7 · Observed 2.2 · Expected 2.1 · Used in QM five-star |
| 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 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 92.1% · 4Q avg 97.5% |
| 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 · 4Q avg 95.6% |
| 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 · Q1 4.8% · Q2 3.8% · Q3 4.1% · Q4 3.4% · 4Q avg 4.0% · Used in QM five-star |
| 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 · Q1 12.3% · Q2 16.2% · Q3 4.3% · Q4 2.7% · 4Q avg 8.7% |
| 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 · Q1 3.7% · Q2 6.7% · Q3 2.8% · Q4 3.5% · 4Q avg 4.2% |
| 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 · Q1 27.2% · Q2 26.3% · Q3 27.8% · Q4 25.3% · 4Q avg 26.6% |
| 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 · Q1 10.0% · Q2 15.2% · Q3 10.8% · Q4 21.7% · 4Q avg 14.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 5.7% · Q2 5.5% · Q3 5.2% · Q4 14.9% · 4Q avg 8.3% · Used in QM five-star |
| 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 · Q1 11.3% · Q2 7.3% · Q3 11.5% · Q4 18.3% · 4Q avg 12.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 4.8% · Q2 1.3% · Q3 1.4% · Q4 1.1% · 4Q avg 2.2% · Used in QM five-star |
| 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 · Q1 21.6% · Q2 24.5% · Q3 24.7% · Q4 30.0% · 4Q avg 25.4% |
| 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 · Q1 16.4% · Q2 12.2% · Q3 10.9% · Q4 12.0% · 4Q avg 13.0% · Used in QM five-star |
| 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 · Q1 71.4% · Q2 85.5% · Q3 72.7% · Q4 69.2% · 4Q avg 74.2% |
| 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 · Adjusted 8.6% · Observed 11.1% · Expected 14.4% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 5.7% · 4Q avg 3.2% · Used in QM five-star |
| 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 · 4Q avg 86.0% |
| 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 · Adjusted 29.7% · Observed 46.0% · Expected 36.9% · Used in QM five-star |
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
Other facilities in reach
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Arbor Ridge Rehabilitation And Healthcare Center
Wayne, NJ
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Llanfair House Care & Rehabilitation Center
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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