01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-21 | 7 | 2025-03-21 | 16 |
| Cycle 2 | 2023-03-30 | 0 | 2023-03-30 | 4 |
| Cycle 3 | 2020-10-30 | 2 | 2020-10-30 | 0 |
CMS CCN 3152472026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At West Caldwell Llc
165 Fairfield Ave · West Caldwell, NJ 07006 · Essex County
Certified beds180CMS provider file
Recent citation rows29current CMS citation release
Penalty rows0current 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
29 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-11-26 · 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 · 2025-12-18 · complaint2025-03-21 · 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 · 2025-04-102025-03-21 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · HEALTHF0698Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-04-10 · complaint2025-03-21 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · HEALTHF0835Severity F · widespread; potential for more than minimal harm
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 · 2025-04-102025-03-21 · HEALTHF0837Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0211Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-04-162025-03-21 · FIREK0225Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0311Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · 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 · 2025-04-182025-03-21 · FIREK0362Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-04-182025-03-21 · FIREK0531Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have elevators that firefighters can control in the event of a fire.
Correction field: Deficient, Provider has date of correction · 2025-04-182025-03-21 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0912Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have power receptacles that are properly grounded.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-04-172025-03-21 · FIREK0919Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Correction field: Deficient, Provider has date of correction · 2025-04-172025-03-21 · FIREK0920Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-04-102025-03-21 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-04-102023-03-30 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2023-04-2803 / 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 |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PC HMH OPCO HOLDINGS 2 LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/03/2023
- PC HMH HOLDINGS 2 LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 11/03/2023
- SMS 2021 TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 11/03/2023
- DES CAPITAL LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/03/2023
- JRK INVESTMENTS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/03/2023
- PEACE CAPITAL HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/03/2023
- KLUGMAN, JACOBIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/03/2023
- STEIN, SHALOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/03/2023
- STERNBUCH, DANIELIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/03/2023
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/03/2023
- GUGLIELMO, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/03/2023
- STEIN, SHALOMIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 11/03/2023
- DES CAPITAL LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/03/2023
- JRK INVESTMENTS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/03/2023
- PC HMH HOLDINGS 2 LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/03/2023
- PC HMH PROPCO HOLDINGS 2 LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/03/2023
- PEACE CAPITAL HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/03/2023
- SMS 2021 TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/03/2023
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 hours3.44per resident day
RN hours0.44per resident day
Weekend nurse hours3.14per resident day
Staff turnover51.7%CMS reported field
06 / LOCAL RECORDS
Open the West Caldwell ledger →