SNF
COMPLETE CARE AT WEST CALDWELL LLC
CCN: 315247 · WEST CALDWELL, NJ 07006 · Essex County
Overview
- Address
- 165 FAIRFIELD AVE, WEST CALDWELL, NJ 07006
- Phone
- 9732261100
- Certified beds
- 180
- Avg daily residents
- 138 (76% of beds filled)
- Ownership
- For-profit LLC
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1987-10-01
- Setting
- Urban
4 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.53 | 4.02 | 3.39 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.53 | 0.70 | 0.51 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.80 | 0.89 | 0.77 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.20 | 2.43 | 2.11 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.33 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.08 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.11
hrs / resident / day
RN (weekend)
0.30
hrs / resident / day
Total nurse (adjusted, weekend)
2.98
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
46.2%
annual
RN turnover
52.2%
annual
Administrators departed
2
last 12 months
Resident acuity
Nursing Case-Mix Index
1.43
higher acuity than avg
Case-Mix Index Ratio
1.03
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-03-21 | 7 | 6 | 2 | 56 | 1 | 56 |
| Cycle 2/3 (prior) | 2023-03-30 | 1 | 0 | 1 | 4 | 1 | 4 |
Total weighted health score
43.0
lower is better
Deficiencies (10)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
10 D/E/F Actual harm — potential for minor
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0610 | Respond appropriately to all alleged violations. | D | 2025-11-26 | 2025-12-18 |
| 0641 | Ensure each resident receives an accurate assessment. | D | 2025-03-21 | 2025-04-10 |
| 0697 | Provide safe, appropriate pain management for a resident who requires such services. | D | 2025-03-21 | 2025-04-10 |
| 0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | 2025-03-21 | 2025-04-10 |
| 0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F | 2025-03-21 | 2025-04-10 |
| 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. | F | 2025-03-21 | 2025-04-10 |
| 0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E | 2025-03-21 | 2025-04-10 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2023-03-30 | 2023-04-14 |
| 0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | 2020-10-30 | 2020-11-13 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2020-10-30 | 2020-11-13 |
Financial Health (FY 2023)
Payer mix (share of resident days)
Medicare 5.9% Medicaid 63.6% Other 30.5%
Operating performance
Operating Margin
-49.5%
Total Margin
-29.9%
Occupancy Rate
68.3%
Cost per Resident Day
$50
Revenue & costs
Net Patient Revenue
$14.9M
Total Costs
$2.3M
Net Income
-$5.1M
Balance sheet
Total Assets
$3.0M
Total Liabilities
$3.3M
Fund Balance
-$253K
Current Ratio
0.81
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: COMPLETE CARE
- Chain ID
157- Facilities in chain
- 85
- Legal business name
- Legal Business Name Not Available
Chain-average star ratings (for peer context)
Overall
3.2
Health
2.7
Staffing
2.5
QM
4.4
Owner / manager individuals (1)
| Name | Role | Association |
|---|---|---|
| — | Ownership Data Not Available | — |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $50 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 0.81 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 63.6% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 5.9% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-5,130,900 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $14,910,478 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 68.3% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -49.5% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $3,004,950 | metrics.total_assets |
| Cost Report | Total Costs ($) | $2,252,676 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $-252,762 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $3,257,712 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -29.9% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.77080 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.11076 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.50935 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.39091 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 2.98333 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 137.5 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.89324 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.42763 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.70407 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 4.02495 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.54756 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 2.7 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 3.2 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 4.4 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 2.5 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 157 | Chain ID |
| Provider Information | Chain Name | COMPLETE CARE | Chain Name |
| Provider Information | City/Town | WEST CALDWELL | City/Town |
| Provider Information | CMS Certification Number (CCN) | 315247 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Essex | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1987-10-01 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 3 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 40.8586 | Latitude |
| Provider Information | Legal Business Name | Legal Business Name Not Available | Legal Business Name |
| Provider Information | Location | 165 FAIRFIELD AVE,WEST CALDWELL,NJ,07006 | Location |
| Provider Information | Long-Stay QM Rating | 5 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -74.286 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 2 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 180 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 85 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.42586 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 1.03499 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 4 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Limited Liability company | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 165 FAIRFIELD AVE | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | COMPLETE CARE AT WEST CALDWELL LLC | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 200 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 56 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 2 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 6 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-03-21 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 56 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 7 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 0 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2023-03-30 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 4 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 1 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 4 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 1 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.29677 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 52.2 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.33454 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.80354 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.20042 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.08436 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.53099 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.53496 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 5 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 2 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | NJ | State |
| Provider Information | Telephone Number | 9732261100 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.11006 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 46.2 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 43.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 07006 | ZIP Code |