Cycle 1
Health 2025-07-24 · Fire 2025-07-24
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cedar Grove, NJ
Complete Care At St Vincents LLC
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
315 East Lindsley Road, Cedar Grove, NJ
(973) 754-4800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
151
Certified beds
Average residents
137
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1983-07-01
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
0.55
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.75
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
3.38
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,380
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.68
Baseline 18.68% · Performance 19.73% · Measure score 3.68 · Achievement 3.68 · Improvement 0
Healthcare-associated infections
2.13
Baseline 7.83% · Performance 7.20% · Measure score 2.13 · Achievement 2.13 · Improvement 1.72
Total nurse turnover
4.88
Performance 43.75% · Measure score 4.88 · Achievement 4.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.28
Baseline 3.25 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 230 · Observed rate 10.43% · Lower 95% interval 7.86% |
| Discharge to community | 45.33% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 200 · Observed rate 36.5% · Lower 95% interval 37.53% |
| 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 166 · Denominator 166 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 166 |
| Discharge self-care score | 68.29% |
53.69%
14.6 pts better
|
Numerator 84 · Denominator 123 |
| Discharge mobility score | 65.04% |
50.94%
14.1 pts better
|
Numerator 80 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 3.01% |
2.29%
0.7 pts worse
|
Numerator 5 · Denominator 166 · Adjusted rate 1.93% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 7.5% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 3.45% |
8.2%
4.7 pts worse
|
Numerator 5 · Denominator 145 |
| Staff flu vaccination coverage | 98.6% |
42%
56.6 pts better
|
Numerator 211 · Denominator 214 |
| Discharge function score | 74.8% |
56.45%
18.3 pts better
|
Numerator 92 · Denominator 123 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 51 · Denominator 51 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 54 · Denominator 54 |
| Resident COVID-19 vaccinations up to date | 7.69% |
25.2%
17.5 pts worse
|
Numerator 7 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.1
About the same
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.2 · 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 | 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 | 0.4% |
2.4%
2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.4% |
11.4%
1 pts better
|
11.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 5.5% · Q3 12.2% · Q4 13.1% · 4Q avg 10.4% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.6%
3.8 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.0% · Q4 0.9% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
19.0%
5.1 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.2% · Q3 14.0% · Q4 12.7% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
13.5%
1.3 pts worse
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 15.7% · Q3 13.8% · Q4 13.1% · 4Q avg 14.8% · 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 | 8.6% |
9.8%
1.2 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 16.9% · Q3 7.0% · Q4 6.1% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
9.7%
2.6 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.5% · Q3 8.5% · Q4 3.1% · 4Q avg 7.1% · 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 | 20.1% |
15.9%
4.2 pts worse
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 18.9% · Q3 16.2% · Q4 22.7% · 4Q avg 20.1% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
6.0%
4.1 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.7% · Q3 0.5% · Q4 1.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
78.7%
20.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 99.1% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
8.2%
8.3 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 13.5% · Expected 9.2% · 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 | 94.3% |
80.1%
14.2 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
25.4%
5.4 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 17.3% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-09-28 · Fire 2021-09-28
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-24
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 2025-10-02
F · Potential for more than minimal harm
2025-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-28
F · Potential for more than minimal harm
2025-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-28
F · Potential for more than minimal harm
2025-07-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-07-24
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 2025-07-25
E · Potential for more than minimal harm
2021-09-28
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 2021-10-25
E · Potential for more than minimal harm
2021-09-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-10-25
E · Potential for more than minimal harm
2021-09-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-10-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-01-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-05
E · Potential for more than minimal harm
2024-01-25
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 2024-02-05
J · Immediate jeopardy
2021-09-28
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2021-10-05
E · Potential for more than minimal harm
2021-09-28
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 2021-10-11
D · Potential for more than minimal harm
2021-09-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-28
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2021-10-11
D · Potential for more than minimal harm
2021-09-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-10-11
B · Minimal harm
2021-09-28
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-10-11
Penalties and ownership
What sits behind the stars
Ownership
Pc St. Vincent's Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Gadarla, Mamatha
Operational/Managerial Control · Individual
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Pc St. Vincent's Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Romano-Diaz, Tiffany
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Arbor Glen Center
Cedar Grove, NJ
1-star overall rating with 1-star inspections with $8,281 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Complete Care At Cedar Grove
Cedar Grove, NJ
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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
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