Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT CHESTNUT HILL LLC
PASSAIC, NJ · 111 certified beds · Last Life Safety survey June 12, 2026
CMS Certification Number 315085 · first certified April 1968
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed April 30, 2021 (change of ownership)from CHESTNUT HILL CONVALESCENT & REHABILITATION CENTER
Position within NJ
14 citations — more than 40% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys on file averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2027 — about 11 months from now. This facility’s last Life Safety survey was June 2026. Facilities in NJ are typically surveyed 16–19 months after the last one (median 17), measured over 464 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0909 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.
How that compares
Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 18, 2022 | 6 |
| December 5, 2024 | 4 |
| June 12, 2026 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 2 | 2026-06-12 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2026-06-12 |
| K-0364 | Install properly constructed windows in hallway walls or doors. | 1 | 2024-12-05 |
| K-0371 | Have properly sized and located compartments to protect residents from smoke. | 1 | 2024-12-05 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2022-08-18 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-12-05 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2026-06-12 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2022-08-18 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 12, 2026 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 26, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 26, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 26, 2026) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (June 26, 2026) |
December 5, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 27, 2024) |
| K-0364 | Install properly constructed windows in hallway walls or doors. | Deficient, Provider has date of correction (January 15, 2025) |
| K-0371 | Have properly sized and located compartments to protect residents from smoke. | Deficient, Provider has date of correction (February 10, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (December 27, 2024) |
August 18, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 7, 2022) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (November 4, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 4, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 11, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 7, 2022) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.