Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT WEST CALDWELL LLC
WEST CALDWELL, NJ · 180 certified beds · Last Life Safety survey March 21, 2025
CMS Certification Number 315247 · first certified October 1987
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed November 3, 2023 (change of ownership)from ESSEX RESIDENTIAL CARE LLC
Position within NJ
20 citations — more than 71% 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 16 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to November 2026. This facility’s last Life Safety survey was March 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 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 three years in Maryland. 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 ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 20 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation 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 20 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
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 | 20 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 30, 2020 | 0 |
| March 30, 2023 | 4 |
| March 21, 2025 | 16 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 2 | 2025-03-21 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-03-21 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-03-21 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2025-03-21 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-03-21 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2025-03-21 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2025-03-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-03-21 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Smoke Deficiencies 5
- Egress Deficiencies 3
- Services Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 21, 2025 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 16, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 18, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 18, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (April 18, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 17, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (April 17, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 10, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (April 10, 2025) |
March 30, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (April 14, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 14, 2023) |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Deficient, Provider has date of correction (April 14, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.