Cycle 1
Health 2025-02-03 · Fire 2025-02-03
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Hackensack, NJ
Complete Care At Regent LLC
2-star overall rating with 2-star inspections with 17 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
50 Polifly Road, Hackensack, NJ
(201) 646-1166
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
170
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1990-05-01
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
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
0.50
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,326
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.15
Baseline 19.27% · Performance 19.97% · Measure score 3.15 · Achievement 3.15 · Improvement 0
Healthcare-associated infections
1.15
Baseline 5.33% · Performance 7.49% · Measure score 1.15 · Achievement 1.15 · Improvement 0
Total nurse turnover
4.33
Baseline 39.58% · Performance 46.00% · Measure score 4.33 · Achievement 4.33 · Improvement 0
Adjusted total nurse staffing
0.97
Baseline 4.45 hours · Performance 3.35 hours · Measure score 0.97 · Achievement 0.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.91% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 5.88% · Lower 95% interval 6.2% |
| Discharge to community | 50.68% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 40.65% · Lower 95% interval 40.38% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 107 · Denominator 108 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 108 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 35 · Denominator 60 |
| Discharge mobility score | 63.33% |
50.94%
12.4 pts better
|
Numerator 38 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 4 · Denominator 108 · Adjusted rate 3.25% |
| Healthcare-associated infections requiring hospitalization | 7.49% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 9.21% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 1.5% |
8.2%
6.7 pts worse
|
Numerator 4 · Denominator 267 |
| Staff flu vaccination coverage | 95.79% |
42%
53.8 pts better
|
Numerator 250 · Denominator 261 |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 33 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 29.69% |
25.2%
4.5 pts better
|
Numerator 19 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.1
0.1 pts worse
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
93.0%
0.3 pts better
|
93.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 96.3% · Q3 97.1% · Q4 97.2% · 4Q avg 93.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
97.2%
About the same
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
2.4%
1 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.5% · Q3 0.7% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
11.4%
6.8 pts better
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.0% · Q3 5.7% · Q4 4.7% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
4.6%
1.6 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 5.4% · Q3 3.8% · Q4 2.2% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
19.0%
5.4 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 13.5% · Q3 14.8% · Q4 12.3% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
13.5%
3.4 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 7.7% · Q3 11.1% · Q4 8.9% · 4Q avg 10.1% · 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 | 14.0% |
9.8%
4.2 pts worse
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 18.8% · Q3 9.0% · Q4 14.0% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
9.7%
3.6 pts worse
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 17.5% · Q3 20.2% · Q4 10.0% · 4Q avg 13.3% · 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 | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 1.5% · Q4 0.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
15.9%
9.3 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 31.6% · Q3 25.7% · Q4 26.5% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
6.0%
0.3 pts better
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.5% · Q3 4.5% · Q4 9.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.8% |
78.7%
23.9 pts worse
|
81.7%
26.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 59.0% · Q3 65.2% · Q4 59.0% · 4Q avg 54.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
8.2%
3.7 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 10.2% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.9% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.2% |
80.1%
9.9 pts worse
|
79.7%
9.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
25.4%
3 pts better
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 22.4% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-02 · Fire 2023-10-02
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-06-14 · Fire 2022-06-14
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-11
F · Potential for more than minimal harm
2025-02-03
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 2025-02-11
F · Potential for more than minimal harm
2025-02-03
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 2025-02-11
F · Potential for more than minimal harm
2025-02-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-02-03
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-02-11
F · Potential for more than minimal harm
2025-02-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-02-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-15
F · Potential for more than minimal harm
2025-02-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-02-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-11
F · Potential for more than minimal harm
2025-02-03
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-02-03
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2025-02-11
F · Potential for more than minimal harm
2023-10-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-10-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-10-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-10-02
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-11-03
F · Potential for more than minimal harm
2022-06-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-07-20
F · Potential for more than minimal harm
2022-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-06-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-07-28
E · Potential for more than minimal harm
2022-06-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-03
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 2025-02-21
F · Potential for more than minimal harm
2025-02-03
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-02-03
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 2025-02-24
E · Potential for more than minimal harm
2025-02-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-10
E · Potential for more than minimal harm
2025-02-03
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 2025-03-10
E · Potential for more than minimal harm
2025-02-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-03
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 2025-02-21
D · Potential for more than minimal harm
2025-02-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-03
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-03
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-24
D · Potential for more than minimal harm
2023-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-02
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 2023-11-03
E · Potential for more than minimal harm
2023-10-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-02
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 2023-11-03
D · Potential for more than minimal harm
2022-06-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-30
D · Potential for more than minimal harm
2022-06-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-30
Penalties and ownership
What sits behind the stars
Ownership
Pc Hmh Opco Holdngs LLC
5% Or Greater Direct Ownership Interest · Organization
Elsebai, Karina
Operational/Managerial Control · Individual
Gottesman, Moshe
Operational/Managerial Control · Individual
Karim, Karim
Operational/Managerial Control · Individual
Pc Hmh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Zackai, Raanan
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Careone At Wellington
Hackensack, NJ
3-star overall rating with 2-star inspections with $18,431 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Complete Care At Prospect Heights LLC
Hackensack, NJ
2-star overall rating with 1-star inspections with $118,483 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Atlas Rehabilitation And Healthcare At Maywood
Maywood, NJ
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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