Complete Care at West Caldwell LLC

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Name

  CMS lists a new legal business name for this home.

CMS lists this as a complaint inspection.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on December 18, 2025.

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• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 5 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0835. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on April 10, 2025.

• Citation F0837. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 10, 2025.

• Citation F0698. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on April 10, 2025.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on April 10, 2025.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on April 10, 2025.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on April 10, 2025.

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CMS lists this as a standard inspection.

• Citation K0211. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on April 16, 2025.

• Citation K0225. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  CMS lists it as corrected on April 10, 2025.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on April 10, 2025.

• Citation K0311. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on April 10, 2025.

• Citation K0321. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on April 10, 2025.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on April 10, 2025.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on April 18, 2025.

• Citation K0362. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

  CMS lists it as corrected on April 10, 2025.

• Citation K0521. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on April 18, 2025.

• Citation K0531. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have elevators that firefighters can control in the event of a fire.

  CMS lists it as corrected on April 18, 2025.

  CMS has cited this home for K0531 2 times since 2023.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on April 10, 2025.

  CMS has cited this home for K0712 2 times since 2023.

• Citation K0912. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have power receptacles that are properly grounded.

  CMS lists it as corrected on April 10, 2025.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on April 17, 2025.

• Citation K0919. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on April 17, 2025.

• Citation K0920. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on April 10, 2025.

• Citation K0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on April 10, 2025.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Name

  CMS lists a new name for this home. It was HACKENSACK MERIDIAN HEALTH WEST CALDWELL C.

• Ownership

  CMS no longer lists a chain for this home.

• Staffing

  Total nurse staffing reported to CMS went from 3.3 to 2.9 hours per resident per day.

CMS lists this as a standard inspection.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on April 28, 2023.

• Citation K0531. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have elevators that firefighters can control in the event of a fire.

  CMS lists it as corrected on April 14, 2023.

• Citation K0908. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

  CMS lists it as corrected on April 14, 2023.

• Citation K0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on April 14, 2023.

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CMS lists this as a standard inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on November 13, 2020.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 13, 2020.

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