Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Chestnut Hill Llc during CMS and state inspections, most recent first.
The facility failed to ensure consistent documentation of residents' code statuses, leading to discrepancies in emergency responses. A resident's POLST indicated a full-code status, while the physician's order stated DNR. Another resident's POLST showed DNR, but the order was not updated after hospitalization. Staff relied on various sources, such as colored dots and POLST binders, which were not always consistent with electronic records.
The facility failed to implement its code status policy correctly, leading to discrepancies between residents' documented wishes and staff actions during emergencies. A resident with a full-code POLST was treated as DNR, while another had conflicting records between a DNR POLST and a full-code physician's order. Staff, including the LNHA, were unaware of these discrepancies, highlighting a lack of training and awareness regarding the facility's policy and protocol.
The facility failed to maintain documentation of its QAPI program, potentially affecting all 103 residents. Despite reviewing various issues in QAPI meetings, the facility could not provide meeting minutes for the past year, as revealed during an interview with the Administrator and other key staff.
The facility failed to update care plans for residents with new medical needs, such as a suprapubic catheter and pressure ulcers, and did not consistently involve residents and families in care plan meetings. Staff acknowledged the need for updates, but they were not implemented, leading to potential unmet care needs.
The facility failed to prevent and treat pressure ulcers for three residents, leading to deficiencies in care. A resident with anoxic brain damage developed a Stage II ulcer due to delayed intervention. Another resident developed a sacral DTI shortly after admission, with delayed assessment and treatment. A third resident's sacral ulcer resolved but reopened due to inadequate preventive measures. Observations showed inconsistent implementation of care plans and treatment orders.
A resident's right to dignity was violated when the Director of Housekeeping entered and searched their room without permission, looking for facility linens and towels. The resident, who was cognitively intact, reported feeling undignified by the intrusion. The facility's policy requires staff to respect residents' private space and obtain permission before entering rooms, which was not followed in this instance.
The facility failed to inform two residents or their representatives about the risks and benefits of psychotropic medications. One resident with Alzheimer's was prescribed Seroquel without documented explanation of risks and benefits. Another resident with dementia was on Rexulti and Seroquel, and their representative's concerns about side effects were not addressed with documented information. The facility's policy mandates education on psychotropic drug use, which was not followed.
A facility failed to provide documentation that a cognitively intact resident received their quarterly financial statements, as required by policy. The resident reported never receiving these statements, and the Business Office staff could not produce signed documentation confirming receipt, despite the facility's system for delivering such statements directly to residents.
A facility failed to accurately complete a PASRR Level I assessment for a resident with schizophrenia, omitting critical information about the resident's mental illness and psychiatric history. The Social Services Director admitted to missing these details and lacked formal PASRR training. The Director of Nursing was also unfamiliar with PASRR requirements, despite the facility's policy mandating compliance with state and federal regulations.
A resident with severe cognitive impairment was observed using oxygen therapy without a current physician's order after returning from a hospital stay. The care plan required oxygen at two liters per minute, but the resident was using three liters per minute without documentation. Staff interviews revealed a lack of adherence to the facility's policy on oxygen administration, as the necessary orders were not in place.
The facility failed to attempt alternative measures before installing bed rails and did not assess entrapment risks for two residents. One resident with muscle weakness and dementia and another with Parkinson's disease had side rails installed without proper assessments. Staff interviews revealed inconsistent procedures for assessing bed rail safety and exploring alternatives, contrary to the facility's policy.
A resident with dementia fell out of bed while receiving care, resulting in a head injury. The facility did not report the incident to the State Agency as required by their policy, which mandates immediate reporting of serious bodily injuries. The Director of Nursing confirmed the oversight.
A resident with dementia and a history of falls fell out of bed while being cared for by a CNA, resulting in injuries including a probable nasal fracture. The facility did not investigate the incident, contrary to its policy requiring immediate investigation of suspected neglect.
The facility failed to provide adequate incontinent care for two residents, leading to potential risks of infections and skin breakdown. One resident, severely cognitively impaired, did not receive thorough cleaning due to mobility issues, while another resident, cognitively intact, was not properly cleaned in the front area. Observations and staff interviews confirmed these deficiencies, highlighting a failure to adhere to the facility's incontinence care policy.
Inconsistent Code Status Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure that residents' code statuses were accurately documented and consistent across their medical records, leading to discrepancies in emergency response situations. For Resident #40, there was a conflict between the POLST form, which indicated a full-code status, and the physician's order, which stated a DNR status. This discrepancy was not communicated to the resident's guardian, who confirmed that the resident's wishes were to be resuscitated in an emergency. Resident #4's situation was similar, with an undated POLST indicating a DNR and DNI status, while the physician's order upon the resident's return from the hospital was not updated to reflect this. The resident's family member, who held medical power of attorney, confirmed the DNR status, but there was no recent discussion with the facility to verify this after the resident's hospitalization. For Resident #36, the POLST indicated a DNR and DNI status, but the physician's orders were inconsistent, showing both full-code and DNR statuses at different times. Staff interviews revealed confusion and reliance on various sources, such as colored dots outside residents' rooms and POLST binders, which were not always updated or consistent with the electronic medical records. This lack of accurate and consistent documentation posed a risk of incorrect emergency responses for the residents involved.
Removal Plan
- Facility's Code Status policy updated to include process for obtaining and reviewing code status
- All nurses educated on verification of code status upon admission, completion of the POLST, updating of code status physician's order and updating of ICCP with code status consistent with POLST and advanced directive, and facility's Code Status policy
- All residents' POLST and advanced directives reviewed for accuracy and updated as needed
- Residents with no POLST or advance directives code statuses verified with the resident or responsible party
Failure to Implement Code Status Policy
Penalty
Summary
The facility failed to ensure that the Licensed Nursing Home Administrator (LNHA) and staff implemented the facility's code status policy correctly during medical emergencies, resulting in discrepancies between residents' documented wishes and the actions taken by staff. This deficiency was identified for three residents. Resident #40 had a Practitioner Orders for Life-Sustaining Treatment (POLST) indicating a full-code status, but a physician's order indicated a do not resuscitate (DNR) status. During an emergency, staff treated the resident as DNR, contrary to the resident's and their guardian's wishes for full resuscitation. Resident #4 had an undated POLST scanned into the electronic medical record (EMR) indicating a DNR status, while a physician's order later indicated a full-code status. The resident's family member confirmed the resident's wish for a DNR status, but the facility's records were inconsistent. Similarly, Resident #36 had a POLST indicating a DNR status, but there was no corresponding physician's order in the EMR, leading to confusion about the resident's code status during emergencies. Interviews with facility staff, including the LNHA, Medical Director, and Director of Nursing (DON), revealed a lack of awareness and training regarding the discrepancies between residents' POLST forms and physician's orders. The LNHA acknowledged that it was the nursing staff's responsibility to ensure proper training on the facility's policy, procedure, and protocol, but was unaware of the issues in implementing the code status policy. The Medical Director and DON also expressed a lack of awareness of the discrepancies and the facility's protocol for verifying code status during emergencies.
Removal Plan
- Facility's Code Status policy was updated
- Educate LNHA on reviewing, developing, and implementing clear policies to staff regarding code status
- Update Resident #4, Resident #36, and Resident #40's code status
- Review all residents' charts to ensure the correct code status
- Educate all nurses on verifying code status upon admission, completion of POLST, updating of an order and care plan with code status
Lack of QAPI Documentation
Penalty
Summary
The facility failed to maintain documentation of its ongoing Quality Assessment and Performance Improvement (QAPI) program, which had the potential to negatively affect all 103 residents residing at the facility. The facility's policy, updated in May, outlined the responsibility of the administrator or designee to ensure all QAPI activities and required documentation were completed and up to date. During an interview with the Administrator, the President of Quality and Processing, and the Director of Clinical Services, it was revealed that while weights, wound reports, maintenance concerns, and laundry issues were reviewed in QAPI meetings, there was no documentation of the meeting minutes for the past year. The facility was unable to provide these minutes before the survey team exited the building.
Care Plan Deficiencies and Lack of Resident Involvement
Penalty
Summary
The facility failed to ensure that care plans were updated for several residents, leading to potential unmet care needs. For one resident, the care plan was not updated to reflect the placement of a new suprapubic catheter after the discontinuation of a urinary catheter. Despite acknowledgment from the MDS Coordinator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) that the care plan should have been updated, it remained unchanged. Additionally, the resident's family member, who held medical power of attorney, was not invited to care plan meetings for about a year, despite expressing a desire to attend. Another resident developed a stage two pressure ulcer, which was treated and resolved, but later developed a stage three pressure ulcer. The care plan was updated to include the treatment of the initial ulcer but lacked additional interventions to prevent further skin breakdown. The care plan was later updated to include interventions for the new ulcer, but it did not include all necessary measures, such as the use of an alternating air mattress or floating of the heels. The ADON and DON acknowledged the need for these updates, but they were not implemented in a timely manner. The facility also failed to hold quarterly care plan meetings with residents and families for several residents. Some residents and their families reported not being invited to these meetings, and the facility's process involved the interdisciplinary team meeting separately without resident or family involvement. The facility's policies required care plans to be reviewed and revised as necessary, with resident and family participation encouraged, but these practices were not consistently followed.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately prevent and treat pressure ulcers for three residents, leading to deficiencies in care. Resident #92 was admitted with conditions that increased the risk of pressure ulcers, such as anoxic brain damage and functional quadriplegia. Despite being identified as at risk, the care plan interventions were not fully implemented. The resident developed a Stage II pressure ulcer on the buttock, and the recommended treatments and interventions, such as turning and repositioning, were not initiated promptly. The care plan was not updated with necessary interventions until several days after the ulcer was first observed, and there was no evidence of consistent implementation of the wound consultant's recommendations. Resident #101 was admitted with a low risk for pressure ulcers but developed a deep tissue injury (DTI) on the sacrum shortly after admission. The facility did not conduct a comprehensive assessment of the wound until a week later, and there was a lack of documentation regarding the implementation of treatment orders and wound consultant recommendations. The resident's representative reported the sacral wound development within the first week, but the facility's response was delayed, indicating a failure to promptly address the skin integrity issues. Resident #13, who had a history of skin integrity issues, developed a Stage II pressure ulcer on the sacrum. Although the ulcer initially resolved, it reopened shortly after, and there was no evidence of new interventions to prevent recurrence. Observations revealed that the resident's heels were not consistently floated as per orders, and there was a lack of documented treatment for the sacral pressure ulcer. The facility's failure to implement and document appropriate interventions and treatments for pressure ulcers contributed to the recurrence and development of new ulcers, highlighting deficiencies in the care provided to these residents.
Violation of Resident's Right to Dignity and Respect
Penalty
Summary
The facility failed to uphold a resident's right to dignity and respect when a staff member entered and searched a resident's room without permission. The incident involved a resident who was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The resident reported that the Director of Housekeeping entered their room and began searching through personal belongings for facility linens and towels, despite being told to leave and not having permission to conduct the search. The resident felt undignified by this intrusion and reported the incident to the Administrator. The Director of Housekeeping justified the search by claiming the items belonged to the facility, but later acknowledged being educated on the policy requiring permission to enter and search a resident's room. The facility's policy on dignity emphasizes respecting residents' private space and property, requiring staff to knock and request permission before entering rooms and handling personal belongings. Despite the Administrator's claim of educating the Director of Housekeeping on this policy, no documentation of the education was provided during the survey.
Failure to Inform Residents of Psychotropic Medication Risks
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed of the risks and benefits associated with taking psychotropic medications. This deficiency was identified for two residents. Resident #82, who was admitted with Alzheimer's disease and had a severely impaired cognitive status, was prescribed Seroquel. However, there was no documented evidence in the electronic medical record (EMR) that the risks and benefits of this antipsychotic medication were explained to the resident or their representative. The Director of Nursing (DON) acknowledged that staff are expected to review and document the risks and benefits of psychotropic medications, but this was not done in this case. Similarly, Resident #89, who was admitted with unspecified dementia and psychotic disturbance, was receiving antipsychotic medications, including Rexulti and Seroquel. The resident's representative expressed concerns about the side effects of these medications, but there was no documentation in the EMR that the risks and benefits were explained to them. An attempt was made to explain the new medication to the resident's representative, but it was unsuccessful, and no further documentation was provided. The facility's policy requires that residents and their representatives be educated on the risks and benefits of psychotropic drug use, but this was not adhered to in these cases.
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide documentation that a resident received their quarterly financial statements, as required by the facility's policy. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reported never receiving any financial statements documenting their personal funds. During an interview, the Business Officer Director confirmed that the facility's system is designed to deliver quarterly financial statements directly to cognitively intact residents. However, the Business Office staff could not produce any signed documentation indicating that the resident had received their quarterly statements, which is a violation of the facility's policy on personal funds management.
Inaccurate PASRR Level I Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I assessment was completed accurately for a resident diagnosed with schizophrenia. The resident's electronic medical record indicated a diagnosis of schizophrenia and a history of psychiatric hospitalizations. However, the PASRR Level I screen did not reflect these critical details, which are necessary for determining the need for Level II services. The Social Services Director (SSD) admitted to missing these details during the review of the PASRR Level I screen and acknowledged the inaccuracy. The SSD revealed that she had not received any formal training on the PASRR process and had been managing the task without proper guidance. The Director of Nursing (DON) also stated unfamiliarity with the PASRR requirements but expected staff to complete them accurately. The facility's policy mandates that all residents receive a PASRR in accordance with state and federal regulations, yet this was not adhered to in this instance, leading to the deficiency.
Lack of Oxygen Therapy Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had the necessary physician's orders in place. Resident #4, who had severe cognitive impairment, was observed using oxygen therapy without a current order after returning from a hospital stay. The resident's care plan indicated the need for oxygen therapy at two liters per minute due to ineffective gas exchange, but upon returning to the facility, no new order for oxygen therapy was written. Observations showed the resident using oxygen at three liters per minute, which was not in accordance with any documented order. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy on oxygen administration. A CNA noted that the resident used oxygen continuously, while an LPN admitted to not seeing an oxygen order and subsequently removed the oxygen tubing. The Director of Nursing confirmed that an order should be in place for both routine and PRN oxygen administration. The facility's policy required verification of a physician's order for oxygen therapy, which was not followed in this case.
Failure to Assess Bed Rail Alternatives and Entrapment Risks
Penalty
Summary
The facility failed to ensure that alternative measures were attempted before the installation of bed rails for two residents, and did not assess the risk of entrapment. Resident #36, who was readmitted with conditions such as muscle weakness, hemiplegia, and dementia, had a care plan that included the use of 1/4 side rails without prior assessment for entrapment or exploration of alternatives. Similarly, Resident #54, diagnosed with Parkinson's disease, also had side rails installed without a completed entrapment risk assessment or consideration of alternative measures. Interviews with facility staff revealed a lack of consistent procedures for assessing bed rail safety and exploring alternatives. The Maintenance Director admitted to measuring gaps between the mattress and bed rail but did not assess for entrapment risks. Nursing staff, including LPNs and the DON, confirmed that initial assessments for bed rail use were conducted, but alternatives were not explored, and ongoing assessments were not performed quarterly. The facility's policy required a person-centered approach and the use of alternatives before bed rail installation, which was not adhered to in these cases.
Failure to Report Allegation of Neglect After Resident Fall
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency (SA) after a resident, diagnosed with dementia and severely cognitively impaired, fell out of bed while staff was providing care. The resident, who had a history of falls, was being attended to by a Certified Nurse Aide (CNA) when they pushed themselves out of the bed, resulting in a fall. The incident led to a head injury, including a laceration to the left eyebrow, bleeding from the nose, and swelling to the left cheek. A subsequent hospital discharge report indicated a probable mild fracture of the nasal bone and a black eye. The Director of Nursing (DON) acknowledged that the incident was not reported to the SA, despite the facility's policy requiring such incidents to be reported immediately, or no later than two hours after the allegation if it involves serious bodily injury. The facility's abuse policy defines neglect as the failure to provide necessary goods or services to avoid physical harm or distress, and mandates reporting all alleged violations to the Administrator and SA. The failure to report this incident represents a deficiency in adhering to these established protocols.
Failure to Investigate Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who fell out of bed while staff was providing care. The resident, diagnosed with dementia and severely cognitively impaired, had a history of falls. On the day of the incident, a CNA was changing the resident and turned them to the right side of the bed, after which the resident pushed themselves out of the bed and fell to the floor. The fall resulted in a laceration to the left eyebrow, blood from the nose, and redness and swelling to the left cheek. A subsequent hospital discharge report indicated a probable mild fracture of the left nasal bone and a left black eye. The Director of Nursing confirmed that the incident was not investigated by the facility, despite the facility's policy requiring an immediate investigation in cases of suspected abuse or neglect. The facility's policy, dated May 2024, mandates protections for residents' health, welfare, and rights, including the prevention of neglect, which is defined as the failure to provide necessary goods or services to avoid physical harm or distress. The lack of investigation into this incident represents a failure to adhere to these policies.
Inadequate Incontinent Care for Two Residents
Penalty
Summary
The facility failed to provide proper incontinent care for two residents, Resident #12 and Resident #87, which had the potential to affect all residents requiring staff assistance with incontinent care. Resident #12, who was severely cognitively impaired and at risk for urinary tract infections (UTIs), was observed receiving inadequate care from CNA #4. During an observation, CNA #4 did not thoroughly clean Resident #12's perineal area after removing a saturated incontinent brief, as she was unable to reach the front area due to the resident's inability to stand properly. This was confirmed by CNA #4, who admitted to the difficulty in providing thorough care under these circumstances. Resident #87, who was cognitively intact but always incontinent of urine and frequently incontinent of bowel, also received inadequate care. During an observation, CNA #4 assisted Resident #87 with toileting and incontinence care but failed to clean the front area thoroughly. CNA #4 only cleaned the areas reachable through the hole in the shower chair and did not adequately clean the front of Resident #87. This was corroborated by CNA #4, who stated that she cleaned the perineal area when the resident stood, but Resident #87 did not stand during the observed care. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) highlighted the importance of thorough incontinent care to prevent skin breakdown and infections, such as UTIs. The facility's policy on incontinence care emphasized the need for appropriate treatment to prevent infections and restore continence. However, the observations and staff interviews revealed that the care provided did not meet these standards, leading to the identified deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Passaic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Hamilton, Llc | 0.6 mi | ★★★★★ | 10 | 0 |
| Atlas Rehabilitation Healthcare At Daughters Of Mo | 1.8 mi | ★★★★★ | 2 | 0 |
| Complete Care At Fair Lawn Edge | 3.7 mi | ★★★★★ | 6 | 0 |
| Alaris Health At The Chateau | 3.9 mi | ★★★★★ | 4 | 0 |
| Barnert Subacute Rehabilitation Center, Llc | 4.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.