All citations for Complete Care at West Caldwell LLC

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Complete Care at West Caldwell LLC

Last standard health inspection on record

March 21, 2025

Showing 1 to 23 of 23 citations

No harm, with potential for more than minimal harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Widespread (many residents). CMS level F.
Health citation F-0835, Administration Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
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.
Widespread (many residents). CMS level F.
Health citation F-0837, Administration Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Widespread (many residents). CMS level F.
Fire safety citation K-0211, Egress Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 16, 2025).
No harm, with potential for more than minimal harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Widespread (many residents). CMS level F.
Fire safety citation K-0225, Egress Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Install emergency lighting that can last at least 1 1/2 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0291, Egress Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Have an enclosure around a vertical opening shaft.
Widespread (many residents). CMS level F.
Fire safety citation K-0311, Smoke Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Widespread (many residents). CMS level F.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
Widespread (many residents). CMS level F.
Fire safety citation K-0324, Smoke Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 18, 2025).
No harm, with potential for more than minimal harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Widespread (many residents). CMS level F.
Fire safety citation K-0362, Smoke Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Widespread (many residents). CMS level F.
Fire safety citation K-0521, Services Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 18, 2025).
No harm, with potential for more than minimal harm
Have elevators that firefighters can control in the event of a fire.
Widespread (many residents). CMS level F.
Fire safety citation K-0531, Services Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 18, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Have power receptacles that are properly grounded.
Widespread (many residents). CMS level F.
Fire safety citation K-0912, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
Widespread (many residents). CMS level F.
Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 17, 2025).
No harm, with potential for more than minimal harm
Meet requirements for the use of electrical equipment.
Widespread (many residents). CMS level F.
Fire safety citation K-0919, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 17, 2025).
No harm, with potential for more than minimal harm
Ensure proper usage of power strips and extension cords.
Widespread (many residents). CMS level F.
Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Ensure that testing and maintenance of electrical equipment is performed.
Widespread (many residents). CMS level F.
Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pattern (more than a few residents). CMS level E.
Health citation F-0698, Quality of Life and Care Deficiencies. Inspection of March 21, 2025. Found during a standard inspection and a complaint inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Respond appropriately to all alleged violations.
Isolated (one or a few residents). CMS level D.
Health citation F-0610, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of November 26, 2025. Found during a complaint inspection.
The home gave a date the problem would be corrected (December 18, 2025).
No harm, with potential for more than minimal harm
Ensure each resident receives an accurate assessment.
Isolated (one or a few residents). CMS level D.
Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Provide safe, appropriate pain management for a resident who requires such services.
Isolated (one or a few residents). CMS level D.
Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).
No harm, with potential for more than minimal harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Isolated (one or a few residents). CMS level D.
Health citation F-0756, Pharmacy Service Deficiencies. Inspection of March 21, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (April 10, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.