Complete Care At West Caldwell Llc
COMPLETE CARE AT WEST CALDWELL LLC in WEST CALDWELL, NJ — inspection on November 26, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor was not able to find the ISC in the investigation documents.
The LNHA stated that she started to work as the LNHA in the facility in June of 2025 and she was not aware of or if an ISC was made and submitted by the previous administrator who resigned from the facility before June of 2025.
The surveyor reviewed the facility's ID.
There was no facility ISC nor staff statements in the documents received by the surveyor.
Statements received by the surveyor were VWSs taken by the local police.On [DATE] at 1:16 PM, the LNHA provided the surveyor of a document titled, Summary of Investigation (SOI).
The SOI indicated under Issue/Concern: On [DATE] at approximately 120 [1:20 am] [Resident #5] was found lying next to [their] bed with a garbage pail at the top of her head.
Under Action/Intervention: Staff immediately began CPR [cardiopulmonary resuscitation] and called 911.Under Conclusion/Plan: There is no evidence of abuse or neglect .Team has concluded .It is most likely the resident [Resident #5] suffered a fatal seizure and rolled off the bed onto the floor and [their] head hit the bedside garbage pail.A review of the facility's Abuse, Neglect, and Exploitation with a Reviewed/Revised date of [DATE] revealed under Policy Explanation and Compliance Guidelines: 1.
The facility will develop and implement written policies and procedures that .b.
Establish policies and procedures to investigate any such allegations.
Under Investigation of Alleged Abuse, Neglect, and Exploitation: B.
Written procedures for investigations include:
- Identifying staff responsible for the investigation .4.
Identifying and interviewing all involved persons, witnesses, and others who might have knowledge of the allegations; .6.
Providing complete and thorough documentation of the investigation.NJAC 8:39-4.1(a)5
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.