Complete Care at West Caldwell LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at West Caldwell LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF835Mar 21, 2025

  Based on observations, interviews, and record review, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was licensed in New Jersey (NJ), who was actively involved in daily oversight to ensure all policies and procedures were implemented and followed in the facility to ensure the residents' physical and psychosocial care needs were met. Refer to F 837 F The evidence was as follows: On 3/17/25 at 8:28 AM, the surveyor observed a posted chain of command on a bulletin board within the facility's entrance that had the Acting Administrator (AA) at the top of list with the letters LNHA and MPA (Master of Public Administration) next to his name. […]

• No harm, potential for more than minimal, widespreadF837Mar 21, 2025

  Based on observation, interview, and record review, it was determined that the facility failed to ensure that the Governing Body (GB) appointed a Licensed Nursing Home Administrator (LNHA) who was actively licensed in the state of New Jersey (NJ) to implement the facility's policies and procedures to ensure the residents' physical and psychosocial care needs were met. Refer to F 835 F The evidence was as follows: On 3/17/25 at 8:28 AM, the surveyor observed a posting of the chain of command in the facility's entrance. […]

• No harm, potential for more than minimal, patternF698Mar 21, 2025

  NJ 163118 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adjust medication administration times to accommodate for scheduled dialysis times. This deficient practice was identified for 1 of 2 resident (Resident #341) reviewed for dialysis and was evidenced by the following: On 3/18/25 at 12:49 PM, the surveyor reviewed the closed records for Resident #341. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; end stage renal (kidney) disease, chronic kidney diseases and diabetes mellitus with diabetic polyneuropathy (multiple nerves throughout the body become damaged or dysfunctional). […]

• No harm, potential for more than minimal, isolatedF610Nov 26, 2025

  Based on interviews and review of pertinent facility documents on [DATE], it was determined that the facility failed to complete and thoroughly investigate the fall incident of a cognitively impaired resident (Resident #5) to rule out abuse and neglect. On [DATE] the resident was found unresponsive on the floor next to their bed with their head in the trash bin lined with clear plastic bag. The facility called 911 and police came. The resident was pronounced dead by EMS [emergency medical services] at bedside. This deficient practice was identified for 1 of 5 residents reviewed and was evidenced by the following:The surveyor reviewed the medical record for Resident #5. […]

• No harm, potential for more than minimal, isolatedF641Mar 21, 2025

  Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 5 residents, Residents #4, reviewed for immunization status. This deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. […]