Cycle 1
Health 2024-11-22 · Fire 2024-11-22
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cedar Grove, NJ
Complete Care At Cedar Grove
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
536 Ridge Road, Cedar Grove, NJ
(973) 239-9300
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
190
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1985-01-11
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
0.42
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,134
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.60
Baseline 21.69% · Performance 20.71% · Measure score 1.60 · Achievement 1.56 · Improvement 1.60
Healthcare-associated infections
2.49
Baseline 11.48% · Performance 9.54% · Measure score 2.49 · Achievement 0 · Improvement 2.49
Total nurse turnover
1.05
Baseline 76.80% · Performance 68.75% · Measure score 1.05 · Achievement 0 · Improvement 1.05
Adjusted total nurse staffing
3.40
Baseline 3.51 hours · Performance 4.04 hours · Measure score 3.40 · Achievement 3.40 · Improvement 1.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.92% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 16% · Lower 95% interval 8.82% |
| Discharge to community | 38.38% |
50.57%
12.2 pts worse
|
Worse than the National Rate · Eligible stays 96 · Observed rate 28.13% · Lower 95% interval 28.07% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 115 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 65.79% |
53.69%
12.1 pts better
|
Numerator 50 · Denominator 76 |
| Discharge mobility score | 73.68% |
50.94%
22.7 pts better
|
Numerator 56 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 0.87% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 115 · Adjusted rate 0.61% |
| Healthcare-associated infections requiring hospitalization | 9.54% |
7.12%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 15.12% · Lower 95% interval 5.78% |
| Staff COVID-19 vaccination coverage | 0.61% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 164 |
| Staff flu vaccination coverage | 98.8% |
42%
56.8 pts better
|
Numerator 164 · Denominator 166 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 57 · Denominator 76 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 70.18% |
25.2%
45 pts better
|
Numerator 40 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.1
0.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
93.0%
6.5 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.1% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
2.4%
2.1 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.4% |
11.4%
6 pts better
|
11.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.4% · Q3 4.1% · Q4 5.6% · 4Q avg 5.4% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
4.6%
3.5 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 1.9% · Q4 1.3% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
19.0%
5.7 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.3% · Q3 13.5% · Q4 15.5% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
13.5%
6 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 9.7% · Q3 6.2% · Q4 5.9% · 4Q avg 7.5% · 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 | 3.5% |
9.8%
6.3 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 5.7% · Q3 1.4% · Q4 5.5% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
9.7%
5.9 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.9% · Q3 4.5% · Q4 7.0% · 4Q avg 3.8% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 17.6% |
15.9%
1.7 pts worse
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 14.0% · Q3 10.3% · Q4 19.4% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
6.0%
0.8 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.1% · Q3 4.7% · Q4 4.6% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
78.7%
20.6 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 98.2% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
8.2%
1.1 pts worse
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
80.1%
17.9 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
25.4%
6.7 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 19.8% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-18 · Fire 2023-08-18
12 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-09-03 · Fire 2021-09-03
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-22
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-12
F · Potential for more than minimal harm
2023-08-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-29
E · Potential for more than minimal harm
2021-09-03
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-09-23
E · Potential for more than minimal harm
2021-09-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-20
D · Potential for more than minimal harm
2021-09-03
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-09-15
D · Potential for more than minimal harm
2021-09-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-09-20
D · Potential for more than minimal harm
2021-09-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-09-27
Inspection history
Recent health citations
B · Minimal harm
2025-04-28
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 2025-06-13
E · Potential for more than minimal harm
2024-11-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-22
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 2024-12-12
D · Potential for more than minimal harm
2024-11-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-12
F · Potential for more than minimal harm
2023-08-18
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-18
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 2023-09-07
F · Potential for more than minimal harm
2023-08-18
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-18
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 2023-09-07
D · Potential for more than minimal harm
2023-08-18
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 2023-09-07
D · Potential for more than minimal harm
2023-08-18
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 2023-09-07
D · Potential for more than minimal harm
2023-08-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-07
Penalties and ownership
What sits behind the stars
Ownership
Pc Nj1 Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Marx, Joseph
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Shaker, David
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Alaris Health At Cedar Grove
Cedar Grove, NJ
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Canterbury At Cedar Grove
Cedar Grove, NJ
1-star overall rating with 1-star inspections with $9,661 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Complete Care At St Vincents LLC
Cedar Grove, NJ
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
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