Passaic, NJ

Complete Care At Hamilton, LLC

2-star overall rating with 2-star inspections with $25,313 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

56 Hamilton Avenue, Passaic, NJ

(973) 773-7070

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

104

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1986-01-06

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

0.72

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.62

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

2.09

Nurse aide staffing · state 2.23 · national 2.35

Total nurse hours

3.43

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

3.09

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.81

CMS adjusted RN staffing hours

Adjusted total hours

3.84

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover · state 39% · national 45%

Total nurse turnover

24%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,255

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

Performance score

30.27

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 21.21% · Performance 21.65% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0.26

Baseline 9.34% · Performance 9.01% · Measure score 0.26 · Achievement 0 · Improvement 0.26

Total nurse turnover

8.35

Baseline 41.56% · Performance 29.54% · Measure score 8.35 · Achievement 8.35 · Improvement 6.69

Adjusted total nurse staffing

3.50

Baseline 3.42 hours · Performance 4.07 hours · Measure score 3.50 · Achievement 3.50 · Improvement 2.28

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.55%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 54 · Observed rate 12.96% · Lower 95% interval 7.44%
Discharge to community	46.23%	50.57% 4.3 pts worse	No Different than the National Rate · Eligible stays 29 · Observed rate 34.48% · Lower 95% interval 30.68%
Medicare spending per beneficiary	1.08	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 54 · Denominator 54
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 54
Discharge self-care score	46.43%	53.69% 7.3 pts worse	Numerator 13 · Denominator 28
Discharge mobility score	21.43%	50.94% 29.5 pts worse	Numerator 6 · Denominator 28
Pressure ulcers or injuries, new or worsened	5.56%	2.29% 3.3 pts worse	Numerator 3 · Denominator 54 · Adjusted rate 5%
Healthcare-associated infections requiring hospitalization	9.01%	7.12% 1.9 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 16.67% · Lower 95% interval 5.47%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 138
Staff flu vaccination coverage	99.28%	42% 57.3 pts better	Numerator 138 · Denominator 139
Discharge function score	50%	56.45% 6.5 pts worse	Numerator 14 · Denominator 28
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 22 · Denominator 22
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	42.86%	25.2% 17.7 pts better	Numerator 12 · Denominator 28

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.8	2.1 1.7 pts worse	1.9 1.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.0 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.5	1.1 2.4 pts worse	1.8 1.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 4.2 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	93.0% 7 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.0%	97.2% 1.8 pts better	95.5% 3.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	2.4% 1.6 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 2.1% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.7%	11.4% 7.7 pts better	11.4% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.4% · Q3 3.8% · Q4 4.1% · 4Q avg 3.7%
Percentage of long-stay residents who lose too much weight	5.0%	4.6% 0.4 pts worse	5.4% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 11.1% · Q4 4.7% · 4Q avg 5.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	34.2%	19.0% 15.2 pts worse	19.6% 14.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 36.6% · Q3 34.4% · Q4 33.3% · 4Q avg 34.2%
Percentage of long-stay residents who received an antipsychotic medication	14.6%	13.5% 1.1 pts worse	16.7% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.0% · Q3 15.6% · Q4 19.6% · 4Q avg 14.6% · 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 6.8% · Q2 10.9% · Q3 6.7% · Q4 6.3% · 4Q avg 7.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.9%	9.7% 3.8 pts better	14.9% 9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 9.8% · Q3 7.0% · Q4 2.5% · 4Q avg 5.9% · 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	1.6%	0.8% 0.8 pts worse	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 3.2% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.2%	15.9% 7.3 pts worse	19.8% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 23.1% · Q3 27.2% · Q4 16.7% · 4Q avg 23.2%
Percentage of long-stay residents with pressure ulcers	6.6%	6.0% 0.6 pts worse	5.1% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 8.3% · Q3 7.1% · Q4 6.0% · 4Q avg 6.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.3%	78.7% 15.6 pts better	81.7% 12.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 92.7% · Q3 94.4% · Q4 100.0% · 4Q avg 94.3%
Percentage of short-stay residents who had an outpatient emergency department visit	14.0%	8.2% 5.8 pts worse	12.0% 2 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 18.2% · Expected 14.5% · 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 · Q2 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	93.2%	80.1% 13.1 pts better	79.7% 13.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	34.5%	25.4% 9.1 pts worse	23.9% 10.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 34.5% · Observed 38.2% · Expected 26.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-09 · Fire 2025-09-09

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-06-27 · Fire 2024-06-27

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

8 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2023-05-26 · Fire 2023-05-26

16 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-09

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-11-03

E · Potential for more than minimal harm 2025-09-09

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-11-03

E · Potential for more than minimal harm 2025-09-09

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-11-03

E · Potential for more than minimal harm 2025-09-09

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-11-03

D · Potential for more than minimal harm 2025-09-09

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-11-03

F · Potential for more than minimal harm 2024-06-27

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 2024-08-14

E · Potential for more than minimal harm 2024-06-27

K341 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-14

E · Potential for more than minimal harm 2024-06-27

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-08-14

E · Potential for more than minimal harm 2024-06-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-06-27

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-06-27

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-06-27

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-08-14

D · Potential for more than minimal harm 2024-06-27

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-14

F · Potential for more than minimal harm 2023-05-26

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-07-21

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-09

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 2025-11-03

D · Potential for more than minimal harm 2025-09-09

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-11-03

D · Potential for more than minimal harm 2025-09-09

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 2025-11-03

D · Potential for more than minimal harm 2025-09-09

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-11-03

D · Potential for more than minimal harm 2025-09-09

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-11-03

D · Potential for more than minimal harm 2025-01-28

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 2025-02-21

J · Immediate jeopardy 2024-10-15

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 2024-10-10

D · Potential for more than minimal harm 2024-06-27

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2024-08-14

G · Actual harm 2024-01-30

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 2024-02-21

F · Potential for more than minimal harm 2023-05-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-07-21

F · Potential for more than minimal harm 2023-05-26

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2023-07-21

E · Potential for more than minimal harm 2023-05-26

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 2023-07-21

E · Potential for more than minimal harm 2023-05-26

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 2023-07-21

E · Potential for more than minimal harm 2023-05-26

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-07-21

E · Potential for more than minimal harm 2023-05-26

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2023-07-21

E · Potential for more than minimal harm 2023-05-26