A
LUTHERAN SOCIAL MINISTRIES CRANES MILL
95/100 score
1.06 hrs RN staffing
3 deficiencies
COMPLETE CARE AT WEST CALDWELL LLC
165 FAIRFIELD AVE, WEST CALDWELL, NJ 07006
B
Facility Assessment
This facility staffs below 0.55 RN hours per resident day — the level the 2024 federal rule, repealed in February 2026, would have required.
Below the repealed 0.55 hr RN benchmark — above average inspection record.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
0.53 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
9
Outstanding
0
Actual harm or worse (G–L)
0
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★★★ (5/5)
Staffing: ★★☆☆☆ (2/5)
|
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NursingHomeGrade Score
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66/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
9 deficiencies found. 9 corrected. None involved actual harm.
Most recent inspection (March 21, 2025)
F
Potential harm — widespread
F0835
Status: Corrected
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies — Deficient, Provider has date of correction, corrected April 10, 2025
F
Potential harm — widespread
F0837
Status: Corrected
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Administration Deficiencies — Deficient, Provider has date of correction, corrected April 10, 2025
D
Potential harm — isolated
F0610
Status: Corrected
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 18, 2025
D
Potential harm — isolated
F0756
Status: Corrected
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 10, 2025
D
Potential harm — isolated
F0697
Status: Corrected
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 10, 2025
E
Potential harm — pattern
F0698
Status: Corrected
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 10, 2025
D
Potential harm — isolated
F0641
Status: Corrected
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 10, 2025
Inspection cycle 3 (October 30, 2020)
D
Potential harm — isolated
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 13, 2020
D
Potential harm — isolated
F0658
Status: Corrected
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 13, 2020
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