Cycle 1
Health 2025-03-10 · Fire 2025-03-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Westfield, NJ
Complete Care At Westfield, LLC
3-star overall rating with 2-star inspections with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1515 Lamberts Mill Road, Westfield, NJ
(908) 233-9700
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
227
Certified beds
Average residents
197
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1970-11-05
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
0.39
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,012
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.87
Baseline 17.84% · Performance 21.03% · Measure score 0.87 · Achievement 0.87 · Improvement 0
Healthcare-associated infections
0
Baseline 7.60% · Performance 8.39% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.06
Baseline 49.72% · Performance 59.35% · Measure score 1.06 · Achievement 1.06 · Improvement 0
Adjusted total nurse staffing
1.67
Baseline 3.30 hours · Performance 3.55 hours · Measure score 1.67 · Achievement 1.67 · Improvement 0.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 229 · Observed rate 10.04% · Lower 95% interval 7.33% |
| Discharge to community | 59.87% |
50.57%
9.3 pts better
|
Better than the National Rate · Eligible stays 194 · Observed rate 51.55% · Lower 95% interval 53.14% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 149 · Denominator 149 |
| Falls with major injury | 1.34% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 149 |
| Discharge self-care score | 70.79% |
53.69%
17.1 pts better
|
Numerator 63 · Denominator 89 |
| Discharge mobility score | 67.42% |
50.94%
16.5 pts better
|
Numerator 60 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 1.34% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 149 · Adjusted rate 1.05% |
| Healthcare-associated infections requiring hospitalization | 8.39% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 11.82% · Lower 95% interval 5.52% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 201 |
| Staff flu vaccination coverage | 99% |
42%
57 pts better
|
Numerator 198 · Denominator 200 |
| Discharge function score | 77.53% |
56.45%
21.1 pts better
|
Numerator 69 · Denominator 89 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 63 · Denominator 63 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 56 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 14.49% |
25.2%
10.7 pts worse
|
Numerator 10 · Denominator 69 |
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 2.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.1
0.2 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
93.0%
6.4 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 100.0% · Q3 99.4% · Q4 98.8% · 4Q avg 99.4% |
| 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 | 1.9% |
2.4%
0.5 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 2.3% · Q4 1.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
11.4%
6.4 pts better
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.1% · Q3 6.0% · Q4 8.6% · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
4.6%
3.2 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.6% · Q3 1.2% · Q4 2.4% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
19.0%
2.6 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 16.2% · Q3 16.1% · Q4 15.6% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
13.5%
5.6 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 15.5% · Q3 20.3% · Q4 20.8% · 4Q avg 19.1% · 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 | 1.3% |
9.8%
8.5 pts better
|
16.3%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 3.9% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.6% |
9.7%
8.1 pts better
|
14.9%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.9% · Q3 1.4% · Q4 1.4% · 4Q avg 1.6% · 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 | 3.7% |
15.9%
12.2 pts better
|
19.8%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 3.1% · Q3 3.5% · Q4 1.8% · 4Q avg 3.7% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.0%
1.8 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 5.1% · Q3 7.1% · Q4 3.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
78.7%
19.5 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 100.0% · Q3 100.0% · Q4 93.9% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
8.2%
0.7 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.4% · Expected 11.0% · 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 | 98.6% |
80.1%
18.5 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
25.4%
3.3 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 24.7% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-13 · Fire 2023-02-13
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2021-05-06 · Fire 2021-05-06
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-10
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 2025-04-07
F · Potential for more than minimal harm
2025-03-10
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 2025-04-11
F · Potential for more than minimal harm
2025-03-10
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-03-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-10
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-10
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-11
F · Potential for more than minimal harm
2023-02-13
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-02-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-02-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-02-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-13
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-02-28
F · Potential for more than minimal harm
2023-02-13
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-24
F · Potential for more than minimal harm
2023-02-13
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-13
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-03-28
E · Potential for more than minimal harm
2023-02-13
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 2023-02-19
E · Potential for more than minimal harm
2023-02-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-03-09
E · Potential for more than minimal harm
2023-02-13
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 2023-03-24
E · Potential for more than minimal harm
2023-02-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-02-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-24
E · Potential for more than minimal harm
2021-05-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-05-06
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 2021-06-18
D · Potential for more than minimal harm
2021-05-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-10
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 2025-03-28
D · Potential for more than minimal harm
2025-03-10
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 2025-03-21
D · Potential for more than minimal harm
2025-03-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-03-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-01-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-24
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-24
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 2025-02-07
D · Potential for more than minimal harm
2025-01-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-24
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 2025-02-07
J · Immediate jeopardy
2023-02-13
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 2023-02-15
E · Potential for more than minimal harm
2023-02-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-17
E · Potential for more than minimal harm
2023-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-13
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 2023-02-17
D · Potential for more than minimal harm
2023-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-02-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-17
F · Potential for more than minimal harm
2021-05-06
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 2021-05-21
Penalties and ownership
What sits behind the stars
Ownership
Pc Nj2 Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Cohen, Yosef
Operational/Managerial Control · Individual
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Schulman, Joseph
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Welltower Op LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Complete Care At Clark LLC
Clark, NJ
5-star overall rating with 4-star inspections with $25,753 in total fines with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Ashbrook Care & Rehabilitation Center
Scotch Plains, NJ
1-star overall rating with 1-star inspections with $98,403 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Care Connection Rahway
Rahway, NJ
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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