Provider Name: COMPLETE CARE AT WEST CALDWELL LLC
Address: 165 FAIRFIELD AVE, WEST CALDWELL, NJ 07006
Phone: (973) 226-1100
County: Essex (200)
Ownership Type: For profit - Corporation
Certified Beds: 180
Average Residents Per Day: 123. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: ESSEX RESIDENTIAL CARE LLC
First Approved Date: October 1, 1987
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 5 ()
QM Rating: 5 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 2 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.47445, LPN Staff Hours Per Day: 0.7359, RN Staff Hours Per Day: 0.6575, Licensed Staff Hours Per Day: 1.3935
Total Nurse Staff Hours Per Day, per resident: 2.86800
Weekend Nurse Staff Hours: 2.29591, Weekend RN Staff Hours: 0.4710
PT Staff Hours Per Day, per resident: 0.1034
Nurse Staff Turnover: 51.0, Nurse Turnover Note:
RN Turnover: 64.3, RN Turnover Note:
Admin Left Number: 3, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9765, Case Mix LPN Hours Per Day: 0.6898, Case Mix RN Hours Per Day: 0.2998
Adjusted Nurse Aide Hours Per Day, per resident: 1.51973, Adjusted LPN Hours Per Day: 0.7873, Adjusted RN Hours Per Day: 0.8263
Total Adjusted Nurse Hours Per Day, per resident: 3.04768
Adjusted Weekend Nurse Hours Per Day, per resident: 2.43975
Health Survey Dates and Scores: Cycle 1: 2023-03-30 (Score: 4), Cycle 2: 2020-10-30 (Score: 12), Cycle 3: 2019-04-25 (Score: 4)
Total Weighted Health Score: 6.667
Reported Incidents: 0, Substantiated Complaints: 5
Infection Control Citations:
Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0
Location and GPS: 165 FAIRFIELD AVE,WEST CALDWELL,NJ,07006 (40.8605, -74.285)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-14
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-15
Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-11-13
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-11-13
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-17
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0039, Version: New
Description: Conduct testing and exercise requirements.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-28
Type: Fire Safety, Tag: 0531, Version: New
Description: Have elevators that firefighters can control in the event of a fire.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-14
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-14
Type: Fire Safety, Tag: 0908, Version: New
Description: Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-14
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-17
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-17
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-17