Passaic, NJ

Complete Care At Chestnut Hill LLC

2-star overall rating with 1-star inspections with Special Focus status with $41,688 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

360 Chestnut Street, Passaic, NJ

(973) 777-7800

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 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

111

Certified beds

Average residents

104

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1968-04-01

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

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

0.78

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

1.90

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

1.28

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

2.64

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.36

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

0.50

CMS adjusted RN staffing hours

Adjusted total hours

3.13

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,225

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

30.37

Composite VBP score used to determine payment impact.

Payment multiplier

0.9859

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.29% · Performance 23.14% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.41

Baseline 13.82% · Performance 8.61% · Measure score 5.41 · Achievement 0 · Improvement 5.41

Total nurse turnover

4.11

Baseline 31.82% · Performance 46.88% · Measure score 4.11 · Achievement 4.11 · Improvement 0

Adjusted total nurse staffing

2.63

Baseline 3.86 hours · Performance 3.83 hours · Measure score 2.63 · Achievement 2.63 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.38%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 98 · Observed rate 14.29% · Lower 95% interval 8.06%
Discharge to community	42.99%	50.57% 7.6 pts worse	No Different than the National Rate · Eligible stays 89 · Observed rate 33.71% · Lower 95% interval 32.37%
Medicare spending per beneficiary	1.39	1.02 0.4 pts worse
Drug regimen review with follow-up	98.88%	95.27% 3.6 pts better	Numerator 88 · Denominator 89
Falls with major injury	1.12%	0.77% 0.4 pts worse	Numerator 1 · Denominator 89
Discharge self-care score	74.07%	53.69% 20.4 pts better	Numerator 40 · Denominator 54
Discharge mobility score	50%	50.94% 0.9 pts worse	Numerator 27 · Denominator 54
Pressure ulcers or injuries, new or worsened	3.37%	2.29% 1.1 pts worse	Numerator 3 · Denominator 89 · Adjusted rate 2.6%
Healthcare-associated infections requiring hospitalization	8.61%	7.12% 1.5 pts worse	No Different than the National Rate · Eligible stays 57 · Observed rate 12.28% · Lower 95% interval 5.34%
Staff COVID-19 vaccination coverage	8.98%	8.2% 0.8 pts better	Numerator 15 · Denominator 167
Staff flu vaccination coverage	75.78%	42% 33.8 pts better	Numerator 169 · Denominator 223
Discharge function score	81.48%	56.45% 25 pts better	Numerator 44 · Denominator 54
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 40 · Denominator 40
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	24.14%	25.2% 1.1 pts worse	Numerator 14 · Denominator 58

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	2.1 0.5 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.2 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.5	1.1 0.6 pts better	1.8 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.6%	93.0% 3.6 pts better	93.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 100.0% · Q3 96.6% · Q4 91.9% · 4Q avg 96.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.9%	97.2% 1.7 pts better	95.5% 3.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9%
Percentage of long-stay residents experiencing one or more falls with major injury	0.9%	2.4% 1.5 pts better	3.3% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.5%	11.4% 6.9 pts better	11.4% 6.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 8.6% · Q4 6.2% · 4Q avg 4.5%
Percentage of long-stay residents who lose too much weight	5.4%	4.6% 0.8 pts worse	5.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.5% · Q3 6.9% · Q4 1.4% · 4Q avg 5.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.1%	19.0% 3.9 pts better	19.6% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.7% · Q3 18.2% · Q4 16.7% · 4Q avg 15.1%
Percentage of long-stay residents who received an antipsychotic medication	7.9%	13.5% 5.6 pts better	16.7% 8.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.3% · Q3 9.5% · Q4 3.8% · 4Q avg 7.9% · 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	7.7%	9.8% 2.1 pts better	16.3% 8.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.4% · Q3 9.2% · Q4 9.6% · 4Q avg 7.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.1%	9.7% 3.4 pts worse	14.9% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 12.1% · Q3 10.4% · Q4 17.9% · 4Q avg 13.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.7% 0.5 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	0.8% 0.5 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.3%	15.9% 7.4 pts worse	19.8% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 15.1% · Q3 34.5% · Q4 23.7% · 4Q avg 23.3%
Percentage of long-stay residents with pressure ulcers	7.4%	6.0% 1.4 pts worse	5.1% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 8.8% · Q3 7.8% · Q4 2.9% · 4Q avg 7.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	53.5%	78.7% 25.2 pts worse	81.7% 28.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 54.4% · Q2 72.4% · Q3 51.9% · Q4 34.9% · 4Q avg 53.5%
Percentage of short-stay residents who had an outpatient emergency department visit	6.0%	8.2% 2.2 pts better	12.0% 6 pts better	Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.7% · Expected 10.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.9%	1.2% 1.7 pts worse	1.6% 1.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 1.9% · Q3 2.0% · Q4 2.1% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.7%	80.1% 3.4 pts worse	79.7% 3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.6%	25.4% 2.2 pts worse	23.9% 3.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 29.5% · Expected 25.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-05 · Fire 2024-12-05

14 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2022-08-18 · Fire 2022-08-18

11 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2020-02-11 · Fire 2020-02-11

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-12-05

K364 · Smoke Deficiencies

Fire Safety

Install properly constructed windows in hallway walls or doors.

Corrected 2025-01-15

F · Potential for more than minimal harm 2024-12-05

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2025-02-10

F · Potential for more than minimal harm 2024-12-05

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Corrected 2024-12-27

F · Potential for more than minimal harm 2022-08-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-10-07

F · Potential for more than minimal harm 2022-08-18

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-11-04

F · Potential for more than minimal harm 2022-08-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-11-04

F · Potential for more than minimal harm 2022-08-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-11

F · Potential for more than minimal harm 2022-08-18

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-08-18

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 2022-10-07

D · Potential for more than minimal harm 2020-02-11

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 2020-02-21

Inspection history

Recent health citations

K · Immediate jeopardy 2024-12-05

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-12-06

K · Immediate jeopardy 2024-12-05

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-12-06

F · Potential for more than minimal harm 2024-12-05

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2024-12-27

E · Potential for more than minimal harm 2024-12-05

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 2024-12-27

E · Potential for more than minimal harm 2024-12-05

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-05

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 2024-12-27

D · Potential for more than minimal harm 2024-12-05

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-05

F568 · Resident Rights Deficiencies

Health

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-05

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 2024-12-27

D · Potential for more than minimal harm 2024-12-05

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-05

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-05

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-12-27

D · Potential for more than minimal harm 2024-12-05

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 2024-12-27

G · Actual harm 2022-08-18