Above 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 West Caldwell Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of epilepsy was found unresponsive on the floor with their head in a trash bin. Despite emergency response efforts, the resident was pronounced dead. The facility did not complete or submit a thorough investigation or required documentation to rule out abuse or neglect, and failed to provide staff statements or a comprehensive internal review as required by policy.
The facility failed to have a Licensed Nursing Home Administrator (LNHA) licensed in New Jersey actively overseeing operations. The Acting Administrator (AA) was not licensed in NJ and was awaiting reciprocity, while the facility relied on another LNHA who was not regularly present. Staff confirmed the AA was recognized as the administrator, despite not holding the required NJ license, compromising effective management and oversight.
The facility failed to appoint a Licensed Nursing Home Administrator (LNHA) with an active New Jersey license. The Acting Administrator (AA) was licensed in another state and awaiting reciprocity, yet had been acting as the administrator since August 2024. Interviews and records confirmed the absence of a properly licensed LNHA overseeing the facility, despite the facility's policy requiring such an appointment.
A facility failed to adjust medication administration times for a resident undergoing dialysis, leading to missed or delayed doses of diabetes medication. The resident, with end-stage renal disease and diabetes, had scheduled dialysis sessions that conflicted with the prescribed medication time. The facility's policy required coordination with the dialysis center, but this was not effectively implemented, resulting in a deficiency.
A facility failed to accurately code the MDS for a resident's immunization status. The resident, with a history of COPD and acute respiratory failure, was marked as having an up-to-date pneumococcal vaccine, despite records showing only a previous Prevnar 13 vaccination. The discrepancy was discussed with facility leadership, and the MDS was modified after surveyor inquiry.
A resident with severely impaired cognition and chronic pain conditions received Percocet for pain levels below the prescribed threshold, contrary to physician orders. The facility's medication administration policy was not followed, as the medication was given for pain levels of 3, 5, and 6, instead of the prescribed range of 7 to 10.
A facility failed to ensure a Consultant Pharmacist identified a drug interaction between Levothyroxine and Calcium Carbonate for a resident. The medications were not consistently spaced four hours apart as required by manufacturer's specifications, which could affect the efficacy of Levothyroxine. The resident's thyroid panel showed fluctuations, but the Consultant Pharmacist did not recommend adjusting the medication timing.
Failure to Investigate Resident Fall and Unexpected Death
Penalty
Summary
The facility failed to complete and thoroughly investigate a fall incident involving a cognitively impaired resident who was found unresponsive on the floor next to their bed with their head in a trash bin lined with a clear plastic bag. The resident, who had a history of epilepsy, developmental disorder, osteoarthritis, muscle weakness, and difficulty walking, was assessed as having severely impaired cognition and required staff assistance for activities of daily living. The incident occurred when a CNA, after hearing a noise, found the resident unresponsive and immediately notified nursing staff, who initiated emergency response procedures. EMS and police arrived, and the resident was pronounced dead at the scene. Despite the seriousness of the event, the facility did not submit a required Investigation, Summary, and Conclusion (ISC) to the state health department, nor did it provide complete investigation documentation, including staff statements. The only available statements were those taken by local police. The facility's own investigation summary lacked thorough documentation and did not include evidence of a comprehensive internal investigation as required by facility policy. The absence of a complete and documented investigation into the incident constituted a failure to rule out abuse and neglect, as mandated by regulatory guidelines.
Facility Lacks Properly Licensed Administrator
Penalty
Summary
The facility failed to ensure that a Licensed Nursing Home Administrator (LNHA) licensed in New Jersey was actively involved in the daily oversight of the facility to ensure compliance with policies and procedures. The Acting Administrator (AA), who was listed as the administrator on the facility's chain of command, was not licensed in New Jersey and was awaiting reciprocity. The AA had been serving as the administrator since August 2024, and the facility relied on another staff member, LNHA #1, who was licensed in New Jersey, for administrative purposes. However, LNHA #1 was not regularly present at the facility, and staff members were unsure of the last time LNHA #1 was on-site. Interviews with various staff members, including the Director of Nursing, Regional Director of Operations, and other facility employees, confirmed that the AA was recognized as the administrator. The AA had signed off on Quality Assurance Performance Improvement (QAPI) meetings as the LNHA, despite not holding a New Jersey license. The facility's job offer and job description for the administrator position required the maintenance of appropriate licenses, specifically a New Jersey Nursing Home Administrator license, which the AA did not possess. This lack of a properly licensed administrator compromised the facility's ability to effectively manage and oversee resident care and operations.
Facility Lacks Licensed Administrator in NJ
Penalty
Summary
The facility failed to ensure that the Governing Body appointed a Licensed Nursing Home Administrator (LNHA) who was actively licensed in the state of New Jersey to implement the facility's policies and procedures. The Acting Administrator (AA) was listed as the administrator, but he was only licensed in another state and was awaiting reciprocity from New Jersey. Despite this, he had been acting as the administrator since August 2024, and there was no evidence that a properly licensed LNHA was overseeing the facility's operations. Interviews with various staff members, including the Director of Nursing, Regional Director of Operations, and other facility employees, confirmed that the AA was recognized as the administrator. However, the previous LNHA, who was licensed in New Jersey, had not been present at the facility since August 2024, and there was no clear oversight from a licensed administrator. The facility's records, including the Administrator Job Offer and Job Description, indicated that the AA's position was contingent upon maintaining appropriate licenses, which he did not have for New Jersey. The facility's Governing Body policy required the appointment of a licensed administrator responsible for the management of the facility. Despite this requirement, the AA attended Quality Assurance Performance Improvement (QAPI) meetings and signed documents as the LNHA without holding a valid New Jersey license. The facility's oversight meetings and communications with the Governing Body did not address the lack of a licensed administrator, and the facility continued to operate without compliance with state licensing requirements.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to adjust medication administration times to accommodate a resident's scheduled dialysis sessions. The resident, who had diagnoses including end-stage renal disease, chronic kidney disease, and diabetes mellitus with diabetic polyneuropathy, was receiving dialysis on Mondays, Wednesdays, and Fridays. Despite this schedule, the resident's diabetes medication, Novolog, was consistently scheduled for administration at 4:30 PM, a time when the resident was at the dialysis center. The electronic Medication Administration Record (eMAR) showed that the Novolog was often not administered at the scheduled time, with several instances marked as the resident being asleep or left blank. On some occasions, the medication was administered much later in the evening, well after the resident's return from dialysis. Additionally, there was no evidence in the resident's medical record of an A1C test being conducted to monitor blood sugar levels, nor were results from the dialysis center included. During meetings with the surveyors, facility leadership acknowledged the inconsistency between medication administration times and dialysis schedules. They noted that a mock survey had previously identified this issue. The facility's policy required communication with the dialysis center regarding medication administration, but this was not effectively implemented, contributing to the deficiency.
Inaccurate MDS Coding for Resident's Immunization Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding their immunization status, as observed during a survey. The deficiency was identified for one of the five residents reviewed, specifically concerning the pneumococcal vaccine status. The resident in question, who was alert and conversant, was observed in bed receiving oxygen therapy. The resident's medical history included chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. The most recent quarterly MDS indicated that the resident's pneumococcal vaccine was up to date, marked as 'Yes' in the assessment. However, upon reviewing the electronic medical record, it was found that the resident had only received the Prevnar 13 vaccine in 2021, with no documentation of receiving the recommended follow-up vaccine or a declination of it. This discrepancy was discussed with the facility's Director of Nursing, Licensed Nursing Home Administrator, Administrator in Training, and the Vice President of Clinical. The MDS was subsequently modified after the surveyor's inquiry, but no further information was provided to address the initial coding error.
Improper Pain Management Administration
Penalty
Summary
The facility failed to ensure a pain management regimen was followed in accordance with physician orders for a resident with severely impaired cognition. The resident, who was admitted with diagnoses including non-pressure chronic ulcers and peripheral vascular disease, reported severe pain. The resident's pain management order specified the administration of Percocet for pain levels between 7 and 10. However, the medication was administered on multiple occasions for pain levels below 7, contrary to the physician's order. The resident's electronic Medication Administration Record showed instances where Percocet was given for pain levels of 3, 5, and 6, which did not align with the prescribed pain scale. This discrepancy was confirmed during a meeting with the facility's President of Clinical and the Infection Preventionist, who acknowledged the incorrect administration of the medication. The facility's policy on administering medications emphasizes that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Failure to Identify Drug Interaction in Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist identified and addressed a drug interaction between Levothyroxine and Calcium Carbonate for a resident. The manufacturer's specifications for Levothyroxine, including Levoxyl and Synthroid, indicate that it should be administered at least four hours apart from Calcium Carbonate to prevent reduced efficacy due to the formation of an insoluble chelate. However, the Consultant Pharmacist did not recommend this separation in the medication regimen review, and the resident's medication administration records showed that Levothyroxine and Calcium Carbonate were not consistently spaced four hours apart. The resident involved had medical diagnoses including chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. The resident's thyroid panel results showed fluctuations in thyroid-stimulating hormone and Free T4 levels, which were initially outside normal limits but later returned to normal. Despite these fluctuations, the Consultant Pharmacist did not identify the need for spacing the medications as an irregularity, citing professional satisfaction with the existing spacing. The facility's policy for Medication Regimen Review requires a thorough review to prevent and resolve medication-related problems, but this was not adhered to in this case.
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What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Caldwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Social Ministries Cranes Mill | 1.3 mi | ★★★★★ | 0 | 0 |
| St Catherine Of Siena | 1.9 mi | ★★★★★ | 0 | 0 |
| Arbor Glen Center | 2.8 mi | ★★★★★ | 29 | 0 |
| Alaris Health At Cedar Grove | 2.9 mi | ★★★★★ | 28 | 0 |
| Canterbury At Cedar Grove | 3.1 mi | ★★★★★ | 13 | 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.