B
78/100COMPLETE CARE AT WEST CALDWELL LLC Inspection Report, Violations & Safety Grade (WEST CALDWELL, New Jersey)
165 FAIRFIELD AVE, WEST CALDWELL, New Jersey 07006
Phone: 9732261100
CMS Overall:4/5
Overview & Bed Count
Certified Beds
180
Avg Residents/Day
152.8
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Essex
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health3/5
Staffing2/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | New Jersey Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.46 | 0.70 | -0.24 |
| Total Nurse Hours per Resident per Day | 3.44 | 3.90 | -0.47 |
| CMS Staffing Rating | 2/5 | 3.2/5 | - |
| Nursing Staff Turnover | 44.3% | 39.3% | - |
Health Citation History
9 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-11-26 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-03-21 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F – Moderate Harm Potential |
| 2025-03-21 | Administration Deficiencies | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | F – Moderate Harm Potential |
| 2025-03-21 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E – Moderate Harm Potential |
| 2025-03-21 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2025-03-21 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-03-21 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2020-10-30 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2020-10-30 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
20 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-03-21 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2025-03-21 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | F – Moderate Harm Potential |
| 2025-03-21 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | F – Moderate Harm Potential |
| 2025-03-21 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2025-03-21 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2025-03-21 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-03-21 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-03-21 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | F – Moderate Harm Potential |
| 2025-03-21 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2025-03-21 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | F – Moderate Harm Potential |
| 2025-03-21 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-03-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | F – Moderate Harm Potential |
| 2025-03-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-03-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | F – Moderate Harm Potential |
| 2025-03-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | F – Moderate Harm Potential |
| 2025-03-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | F – Moderate Harm Potential |
| 2023-03-30 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2023-03-30 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | F – Moderate Harm Potential |
| 2023-03-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | F – Moderate Harm Potential |
| 2023-03-30 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WEST CALDWELL area at no cost.
Find Safe, Vetted Facilities Near WEST CALDWELL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.