COMPLETE CARE AT CHESTNUT HILL LLC
Open-data reference.
COMPLETE CARE AT CHESTNUT HILL LLC is a for profit - limited liability company facility in PASSAIC, NJ with 111 certified beds and a 2-star overall CMS rating. The facility has 27 deficiency records on file. Total penalties: $42K.
360 CHESTNUT STREET, PASSAIC, NJ 07055
Phone: 9737777800
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 315085
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 111
- Residents
- 104
- In Hospital
- No
- County
- Passaic
- Last Inspection
- Dec 5, 2024
- Special Focus
- SFF Candidate
Staffing Data
- RN Hours
- 0.51 (nat'l avg: 0.68)
- LPN Hours
- 0.78
- CNA Hours
- 1.90
- Total Nursing Hours
- 3.19 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 54.5%
- RN Turnover
- 42.9%
What the CMS Record Reveals About COMPLETE CARE AT CHESTNUT HILL LLC
COMPLETE CARE AT CHESTNUT HILL LLC operates 111 certified beds in PASSAIC, NJ with approximately 104 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 27 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $42K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.19 total nursing hours per resident day (national average 3.89), with RN coverage at 0.51 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, COMPLETE CARE AT CHESTNUT HILL LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 54.5%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (27 most recent)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 27, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 27, 2024
Have a plan that describes the process for conducting QAPI and QAA activities.
Category: Administration Deficiencies
Corrected: Dec 27, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Dec 6, 2024
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.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 27, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 27, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 27, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Dec 6, 2024
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Category: Resident Rights Deficiencies
Corrected: Dec 27, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Dec 27, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Dec 27, 2024
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Category: Environmental Deficiencies
Corrected: Sep 30, 2022
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Sep 30, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 30, 2022
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 30, 2022
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 30, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 30, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 30, 2022
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 30, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Sep 30, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Sep 30, 2022
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Sep 30, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Feb 21, 2020
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 21, 2020
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 5.4% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.3% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 96.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 53.5% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.9% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 7.7% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.1% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.9% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 76.7% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 7.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 23.3% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 7.9% | Yes |
Penalty History 1 penalties totaling $42K
| Date | Type | Amount |
|---|---|---|
| Dec 5, 2024 | Fine | $42K |
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County Health Data
Health outcomes, access, and quality metrics for Passaic on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for COMPLETE CARE AT CHESTNUT HILL LLC?
What are the staffing levels at COMPLETE CARE AT CHESTNUT HILL LLC?
How many beds does COMPLETE CARE AT CHESTNUT HILL LLC have?
Does COMPLETE CARE AT CHESTNUT HILL LLC have any deficiencies on record?
Has COMPLETE CARE AT CHESTNUT HILL LLC received any fines or penalties?
Who owns COMPLETE CARE AT CHESTNUT HILL LLC?
When was COMPLETE CARE AT CHESTNUT HILL LLC last inspected?
What quality measures are tracked for COMPLETE CARE AT CHESTNUT HILL LLC?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.