Cycle 1
Health 2025-07-24 · Fire 2025-07-24
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Plainfield, NJ
Complete Care At Woodlands
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1400 Woodland Ave, Plainfield, NJ
(908) 753-1113
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1989-04-07
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
0.71
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,532
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9969
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.51
Baseline 18.22% · Performance 19.34% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Healthcare-associated infections
2.55
Baseline 6.45% · Performance 7.07% · Measure score 2.55 · Achievement 2.55 · Improvement 0
Total nurse turnover
8.13
Baseline 32.95% · Performance 30.44% · Measure score 8.13 · Achievement 8.13 · Improvement 2.61
Adjusted total nurse staffing
2.37
Baseline 3.84 hours · Performance 3.75 hours · Measure score 2.37 · Achievement 2.37 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.95% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 216 · Observed rate 14.35% · Lower 95% interval 9.07% |
| Discharge to community | 67.7% |
50.57%
17.1 pts better
|
Better than the National Rate · Eligible stays 204 · Observed rate 56.37% · Lower 95% interval 57.12% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 138 · Denominator 138 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 138 |
| Discharge self-care score | 65.75% |
53.69%
12.1 pts better
|
Numerator 48 · Denominator 73 |
| Discharge mobility score | 60.27% |
50.94%
9.3 pts better
|
Numerator 44 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 0.72% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 138 · Adjusted rate 0.63% |
| Healthcare-associated infections requiring hospitalization | 7.07% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 135 · Observed rate 8.15% · Lower 95% interval 4.9% |
| Staff COVID-19 vaccination coverage | 1.56% |
8.2%
6.6 pts worse
|
Numerator 3 · Denominator 192 |
| Staff flu vaccination coverage | 87.64% |
42%
45.6 pts better
|
Numerator 156 · Denominator 178 |
| Discharge function score | 71.23% |
56.45%
14.8 pts better
|
Numerator 52 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 79 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 61.64% |
25.2%
36.4 pts better
|
Numerator 45 · Denominator 73 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.1
0.6 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.3 · 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 | 0.6% |
2.4%
1.8 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.8% |
11.4%
2.4 pts worse
|
11.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 10.4% · Q3 1.3% · Q4 3.8% · 4Q avg 13.8% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
4.6%
4 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.9% |
19.0%
9.1 pts better
|
19.6%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.1% · Q3 6.2% · Q4 12.8% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
13.5%
1.4 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.3% · Q3 12.1% · Q4 15.8% · 4Q avg 12.1% · 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 | 4.3% |
9.8%
5.5 pts better
|
16.3%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 8.0% · Q4 6.4% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.5% |
9.7%
7.2 pts better
|
14.9%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 6.9% · Q4 1.4% · 4Q avg 2.5% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.7% |
15.9%
5.2 pts better
|
19.8%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 10.4% · Q3 13.9% · Q4 10.1% · 4Q avg 10.7% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
6.0%
2.8 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.1% · Q3 2.8% · Q4 2.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
78.7%
20.3 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 100.0% · Q3 100.0% · Q4 96.5% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
8.2%
1.8 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 5.6% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
80.1%
19.4 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
25.4%
2.7 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 21.5% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
8 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-08-19 · Fire 2021-08-19
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
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
2025-07-24
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 2025-09-01
F · Potential for more than minimal harm
2025-07-24
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-01
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 2025-09-01
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 2025-09-24
F · Potential for more than minimal harm
2025-07-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-01
F · Potential for more than minimal harm
2024-02-01
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-02-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-01
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 2024-03-15
E · Potential for more than minimal harm
2024-02-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-01
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-03-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-07-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-01
D · Potential for more than minimal harm
2024-09-25
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 2024-10-23
E · Potential for more than minimal harm
2024-02-01
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 2024-02-28
E · Potential for more than minimal harm
2024-02-01
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-01
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 2024-02-22
D · Potential for more than minimal harm
2024-02-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-01
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-11-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-08
E · Potential for more than minimal harm
2021-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-14
D · Potential for more than minimal harm
2021-08-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-19
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 2021-09-10
Penalties and ownership
What sits behind the stars
$0
2024-02-01
Payment Denial
Payment Denial · denial start 2024-05-01 · 5 days
5 day denial
Ownership
Pc Holdings 2 LLC
5% Or Greater Direct Ownership Interest · Organization
Eef Capital LLC
5% Or Greater Direct Ownership Interest · Organization
Bahooshian, Michael
Operational/Managerial Control · Individual
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Nemirovsky, Michael
Operational/Managerial Control · Individual
Pc Holdings 1 LLC
5% Or Greater Indirect Ownership Interest · Organization
Schlaff, Benny
5% Or Greater Indirect Ownership Interest · Individual
Schlaff, Nachum
5% Or Greater Indirect Ownership Interest · Individual
Stein, Shalom
5% Or Greater Indirect Ownership Interest · Individual
Stein, Shalom
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Complete Care At Plainfield LLC
Plainfield, NJ
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
CareOne at The Highlands
Edison, NJ
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
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
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