PlainNursing
2026 data Public-data reference. official source

COMPLETE CARE AT WEST CALDWELL LLC

Open-data reference.

COMPLETE CARE AT WEST CALDWELL LLC is a for profit - limited liability company facility in WEST CALDWELL, NJ with 180 certified beds and a 4-star overall CMS rating. The facility has 10 deficiency records on file.

165 FAIRFIELD AVE, WEST CALDWELL, NJ 07006

Phone: 9732261100

Overall Rating

4/5

Health Inspection

3/5

Staffing

2/5

Quality Measures

5/5

Long-Stay Quality

5/5

Facility Information

Provider Number
315247
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
Beds
180
Residents
138
In Hospital
No
County
Essex
Last Inspection
Mar 21, 2025

Staffing Data

RN Hours
0.53 (nat'l avg: 0.68)
LPN Hours
0.80
CNA Hours
2.20
Total Nursing Hours
3.53 (nat'l avg: 3.89)
PT Hours
0.08
Nursing Turnover
46.2%
RN Turnover
52.2%

What the CMS Record Reveals About COMPLETE CARE AT WEST CALDWELL LLC

COMPLETE CARE AT WEST CALDWELL LLC operates 180 certified beds in WEST CALDWELL, NJ with approximately 138 residents currently in care, and carries a CMS overall rating of 4 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 (3★), 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 10 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.53 total nursing hours per resident day (national average 3.89), with RN coverage at 0.53 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, COMPLETE CARE AT WEST CALDWELL 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 46.2%, within a range generally associated with stable care teams. 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 (10 most recent)

D — Isolated - Minimal harm Nov 26, 2025 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Dec 18, 2025

E — Pattern - Minimal harm Mar 21, 2025 Tag: 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 10, 2025

F — Widespread - Minimal harm Mar 21, 2025 Tag: 0837

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.

Category: Administration Deficiencies

Corrected: Apr 10, 2025

F — Widespread - Minimal harm Mar 21, 2025 Tag: 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Category: Administration Deficiencies

Corrected: Apr 10, 2025

D — Isolated - Minimal harm Mar 21, 2025 Tag: 0756

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: Apr 10, 2025

D — Isolated - Minimal harm Mar 21, 2025 Tag: 0697

Provide safe, appropriate pain management for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 10, 2025

D — Isolated - Minimal harm Mar 21, 2025 Tag: 0641

Ensure each resident receives an accurate assessment.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Apr 10, 2025

D — Isolated - Minimal harm Mar 30, 2023 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 14, 2023

D — Isolated - Minimal harm Oct 30, 2020 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Nov 13, 2020

D — Isolated - Minimal harm Oct 30, 2020 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 13, 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 4.3% Yes
Percentage of long-stay residents who lose too much weight Long Stay 2.2% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.2% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 6.4% 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 1.4% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 99.8% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 100.0% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 1.1% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 4.8% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 18.9% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 100.0% No
Percentage of long-stay residents with pressure ulcers Long Stay 4.9% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 18.2% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 15.4% Yes

Penalty History

No penalties on record.

Frequently Asked Questions

What is the overall CMS rating for COMPLETE CARE AT WEST CALDWELL LLC?
COMPLETE CARE AT WEST CALDWELL LLC has an overall CMS rating of 4 out of 5 stars. This rating combines health inspection results (3★), staffing levels (2★), and quality measures (5★).
What are the staffing levels at COMPLETE CARE AT WEST CALDWELL LLC?
COMPLETE CARE AT WEST CALDWELL LLC reports 3.53 total nursing hours per resident day (national average: 3.89). RN hours are 0.53 per resident day (national average: 0.68). Nursing staff turnover is 46.2%.
How many beds does COMPLETE CARE AT WEST CALDWELL LLC have?
COMPLETE CARE AT WEST CALDWELL LLC has 180 certified beds with approximately 138 residents. The facility is located at 165 FAIRFIELD AVE, WEST CALDWELL, NJ 07006.
Does COMPLETE CARE AT WEST CALDWELL LLC have any deficiencies on record?
Yes, COMPLETE CARE AT WEST CALDWELL LLC has 10 deficiencies on record from recent inspections. Most deficiencies are classified as no harm or minimal harm.
Has COMPLETE CARE AT WEST CALDWELL LLC received any fines or penalties?
No, COMPLETE CARE AT WEST CALDWELL LLC has no fines or penalties on record.
Who owns COMPLETE CARE AT WEST CALDWELL LLC?
COMPLETE CARE AT WEST CALDWELL LLC is classified as "For profit - Limited Liability company" ownership. The facility type is "Medicare and Medicaid".
When was COMPLETE CARE AT WEST CALDWELL LLC last inspected?
The most recent health inspection for COMPLETE CARE AT WEST CALDWELL LLC was on Mar 21, 2025. The facility received a health inspection rating of 3 out of 5 stars.
What quality measures are tracked for COMPLETE CARE AT WEST CALDWELL LLC?
COMPLETE CARE AT WEST CALDWELL LLC is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

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.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial