Complete Care at Chestnut Hill LLC

360 Chestnut Street · Passaic, NJ · 07055 · 9737777800

111 certified beds For profit - Limited Liability company Chain: Complete Care

Why this verdict

  • Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
  • Inspection record is far worse than the national median (deficiency count and severity).
  • Inspection results are getting worse cycle over cycle, not better.

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Red flags

2 immediate-jeopardy citations in the most recent inspection cycle

Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.

Score breakdown

Inspection record 30% of score 24
Serious harm & abuse 20% 34
Staffing 20% 57
Federal penalties 15% 67
Trend 10% 18
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 5 of 5

Total nurse hours / resident-day3.353.48 min · 4.1 strong
RN hours / resident-day0.390.55–0.75
Weekend hours / resident-day2.97≈ weekday level
Nursing turnover / year51%median 45%
Fines (3-yr window)1 · $41,688

Inspection citations (27 in the current record)

  • Immediate jeopardy · K December 5, 2024

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

    Corrected December 6, 2024 · Resident Rights

  • Immediate jeopardy · K December 5, 2024

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    Corrected December 6, 2024 · Administration

  • Potential for harm · D December 5, 2024

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Corrected December 27, 2024 · Resident Rights

  • Potential for harm · D December 5, 2024

    Ensure that residents are fully informed and understand their health status, care and treatments.

    Corrected December 27, 2024 · Resident Rights

  • Potential for harm · D December 5, 2024

    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

    Corrected December 27, 2024 · Resident Rights

  • Potential for harm · D December 5, 2024

    PASARR screening for Mental disorders or Intellectual Disabilities

    Corrected December 27, 2024 · Resident Assessment and Care Planning

  • Potential for harm · E December 5, 2024

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Corrected December 27, 2024 · Resident Assessment and Care Planning

  • Potential for harm · E December 5, 2024

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Corrected December 27, 2024 · Quality of Life and Care

  • Potential for harm · D December 5, 2024

    Provide safe and appropriate respiratory care for a resident when needed.

    Corrected December 27, 2024 · Quality of Life and Care

  • Potential for harm · D December 5, 2024

    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

    Corrected December 27, 2024 · Quality of Life and Care

  • Potential for harm · F December 5, 2024

    Have a plan that describes the process for conducting QAPI and QAA activities.

    Corrected December 27, 2024 · Administration

  • Potential for harm · D December 5, 2024 · found via complaint

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Corrected December 27, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D December 5, 2024 · found via complaint

    Respond appropriately to all alleged violations.

    Corrected December 27, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D December 5, 2024 · found via complaint

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Corrected December 27, 2024 · Quality of Life and Care

  • Actual harm · G August 18, 2022

    Provide enough food/fluids to maintain a resident's health.

    Corrected September 30, 2022 · Quality of Life and Care

  • Potential for harm · D August 18, 2022

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

    Corrected September 30, 2022 · Resident Rights

  • Potential for harm · D August 18, 2022

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected September 30, 2022 · Resident Rights

  • Potential for harm · D August 18, 2022

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Corrected September 30, 2022 · Resident Rights

  • Potential for harm · D August 18, 2022

    Ensure each resident receives an accurate assessment.

    Corrected September 30, 2022 · Resident Assessment and Care Planning

  • Potential for harm · D August 18, 2022

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected September 30, 2022 · Resident Assessment and Care Planning

  • Potential for harm · D August 18, 2022

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Corrected September 30, 2022 · Resident Assessment and Care Planning

  • Potential for harm · D August 18, 2022

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Corrected September 30, 2022 · Quality of Life and Care

  • Potential for harm · D August 18, 2022

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected September 30, 2022 · Resident Assessment and Care Planning

  • Potential for harm · D August 18, 2022

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

    Corrected September 30, 2022 · Infection Control

  • Potential for harm · D August 18, 2022

    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

    Corrected September 30, 2022 · Environmental

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
December 5, 2024Fine$41,688

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 315085 · certified since April 1, 1968. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.