Cycle 1
Health 2025-03-21 · Fire 2025-03-21
7 health deficiencies
Top issue: Administration (2 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
West Caldwell, NJ
Complete Care At West Caldwell LLC
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
165 Fairfield Ave, West Caldwell, NJ
(973) 226-1100
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
180
Certified beds
Average residents
138
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1987-10-01
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
0.53
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,336
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.10
Composite VBP score used to determine payment impact.
Payment multiplier
1.0042
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.07
Baseline 23.61% · Performance 17.97% · Measure score 8.07 · Achievement 7.47 · Improvement 8.07
Healthcare-associated infections
6.13
Baseline 10.13% · Performance 6.73% · Measure score 6.13 · Achievement 3.71 · Improvement 6.13
Total nurse turnover
5.84
Baseline 33.33% · Performance 39.81% · Measure score 5.84 · Achievement 5.84 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.34 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.36% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 213 · Observed rate 7.98% · Lower 95% interval 7.21% |
| Discharge to community | 53.15% |
50.57%
2.6 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 46.2% · Lower 95% interval 46.13% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 150 · Denominator 150 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 150 |
| Discharge self-care score | 67.39% |
53.69%
13.7 pts better
|
Numerator 62 · Denominator 92 |
| Discharge mobility score | 60.87% |
50.94%
9.9 pts better
|
Numerator 56 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 2.67% |
2.29%
0.4 pts worse
|
Numerator 4 · Denominator 150 · Adjusted rate 1.83% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 6.29% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 178 · Denominator 178 |
| Staff flu vaccination coverage | 78.71% |
42%
36.7 pts better
|
Numerator 122 · Denominator 155 |
| Discharge function score | 72.83% |
56.45%
16.4 pts better
|
Numerator 67 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 62 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 3.8% |
25.2%
21.4 pts worse
|
Numerator 3 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.1
0.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
93.0%
6.8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.8% |
| 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 | 1.4% |
2.4%
1 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.3% · Q3 0.8% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
11.4%
5 pts better
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 9.6% · Q3 1.8% · Q4 11.1% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
4.6%
2.4 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 1.0% · Q4 1.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
19.0%
0.1 pts better
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 17.9% · Q3 20.7% · Q4 21.9% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
13.5%
1.9 pts worse
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 16.5% · Q3 16.9% · Q4 16.2% · 4Q avg 15.4% · 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 | 4.8% |
9.8%
5 pts better
|
16.3%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 8.1% · Q3 2.8% · Q4 4.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
9.7%
5.4 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.4% · Q3 6.5% · Q4 3.0% · 4Q avg 4.3% · 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 | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
15.9%
2.3 pts worse
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 20.3% · Q3 20.3% · Q4 16.8% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
6.0%
1.1 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.6% · Q3 2.9% · Q4 4.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.7%
21.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.8% |
8.2%
3.4 pts better
|
12.0%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 4.2% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 1.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.1%
19.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
25.4%
3.2 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 26.7% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2020-10-30 · Fire 2020-10-30
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-03-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
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 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-21
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-17
F · Potential for more than minimal harm
2025-03-21
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-04-17
F · Potential for more than minimal harm
2025-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-10
F · Potential for more than minimal harm
2023-03-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-30
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-18
F · Potential for more than minimal harm
2025-03-21
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-21
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-03-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-10
D · Potential for more than minimal harm
2023-03-30
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 2023-04-14
D · Potential for more than minimal harm
2020-10-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-11-13
D · Potential for more than minimal harm
2020-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-11-13
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Lutheran Social Ministries Cranes Mill
West Caldwell, NJ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
St Catherine Of Siena
Caldwell, NJ
2-star overall rating with 3-star inspections with $16,171 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
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
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