01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-12-05 | 14 | 2024-12-05 | 4 |
| Cycle 2 | 2022-08-18 | 11 | 2022-08-18 | 6 |
| Cycle 3 | 2020-02-11 | 2 | 2020-02-11 | 1 |
CMS CCN 3150852026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At Chestnut Hill Llc
360 Chestnut Street · Passaic, NJ 07055 · Passaic County
Certified beds111CMS provider file
Recent citation rows38current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
38 rows in the current release
3 rows carry G–L scope/severity codes; 2 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-12-05 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0568Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0578Severity K · pattern of immediate jeopardy
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-12-05 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-12-27 · complaint2024-12-05 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-12-27 · complaint2024-12-05 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0657Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0686Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-12-27 · complaint2024-12-05 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · HEALTHF0835Severity K · pattern of immediate jeopardy
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Correction field: Deficient, Provider has date of correction · 2024-12-062024-12-05 · HEALTHF0865Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-12-272024-12-05 · FIREK0364Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install properly constructed windows in hallway walls or doors.
Correction field: Deficient, Provider has date of correction · 2025-01-152024-12-05 · FIREK0371Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have properly sized and located compartments to protect residents from smoke.
Correction field: Deficient, Provider has date of correction · 2025-02-102024-12-05 · FIREK0926Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Correction field: Deficient, Provider has date of correction · 2024-12-272022-08-18 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2022-09-302022-08-18 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2022-09-302022-08-18 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-09-302022-08-18 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2022-09-302022-08-18 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2022-09-302022-08-18 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2022-09-3003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-12-05 | Fine | $41,688 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHESTNUT HILL HOLDCO LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/30/2021
- EEF CAPITAL LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 04/30/2021
- PC CHESTNUT HILL HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 04/30/2021
- SCHLAFF, BENNYIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 04/30/2021
- SCHLAFF, NACHUMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 04/30/2021
- SCHWARTZ, HERSHELIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 04/30/2021
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/30/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.23per resident day
RN hours0.38per resident day
Weekend nurse hours2.78per resident day
Staff turnover41.8%CMS reported field
06 / LOCAL RECORDS
Open the Passaic ledger →