Inspection Reports for
Chestnut Hill Residences By Complete Care
338 Chestnut Street, Passaic, NJ, 07055
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
102 residents
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the department's legal duties and responsibilities regarding privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 3
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ00172057) due to allegations regarding failure to develop and implement a policy on the use of a Universal Transfer Form and concerns related to resident abuse and safety.
Complaint Details
Complaint #: NJ00172057. The complaint involved failure to implement a Universal Transfer Form policy, resident abuse between Resident #2 and Resident #3 by a Home Health Aide, and unsafe living conditions including malfunctioning door locks and inaccessible call bell cords. The facility submitted a Facility Reportable Event and revised policies following the investigation.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards, failing to implement a Universal Transfer Form policy, failing to protect residents from abuse, and failing to ensure safe living conditions including functional door locks and accessible call lights. The facility revised policies and implemented corrective actions by the revisit date.
Deficiencies (3)
Failure to develop and implement a policy and procedure on the use of a Universal Transfer Form (UTF) for residents.
Failure to ensure residents' right to be free from physical and mental abuse and/or neglect, evidenced by an incident involving Resident #2 and Resident #3.
Failure to ensure a safe environment while providing care and services, including issues with call bell accessibility and door lock functionality for Resident #2.
Report Facts
Census: 102
Sample Size: 4
Date of Incident: Mar 21, 2024
Date of Survey Completion: Apr 4, 2024
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Date: Mar 1, 2024
Visit Reason
The inspection was a standard survey with complaints, triggered by multiple complaint numbers (NJ00154586, NJ00154024, NJ00154340, NJ00161411, NJ00166050) to assess compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences.
Complaint Details
The complaint investigation involved multiple complaint numbers including NJ00154586, NJ00154024, NJ00154340, NJ00161411, and NJ00166050. The facility failed to immediately notify the Department of Health of an incident involving Resident #1, which was reported late after a delay caused by the Executive Director waiting for insurance company correspondence.
Findings
The facility was found not in substantial compliance with all standards, specifically failing to immediately notify the Department of Health of a suspected case of resident abuse or exploitation involving Resident #1. The facility submitted a plan of correction and was subject to enforcement actions if deficiencies were not corrected.
Deficiencies (1)
Failure to immediately notify the Department of Health of a suspected case of resident abuse or exploitation for Resident #1.
Report Facts
Census: 100
Sample size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding delayed reporting of Resident #1's incident to the Department of Health | |
| Licensed Practical Nurse (LPN) | Documented Resident #1's condition and incident in progress notes |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Mar 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of staff to resident physical abuse reported to have occurred on 2021-03-18 at the facility.
Complaint Details
Complaint # NJ 00143955 involved an allegation of staff to resident physical abuse reported on 2021-03-18. The investigation was incomplete, and the CNA was not reassigned or suspended pending investigation outcome. The allegation was substantiated by interviews and record review.
Findings
The Executive Director failed to ensure the implementation of the facility's Abuse Investigations Policy when a Certified Nursing Assistant (CNA) continued to care for residents despite an allegation of physical abuse, and the investigation of the allegation was not completed prior to the CNA returning to work. The facility was found not in substantial compliance with licensure standards.
Deficiencies (1)
Failure to implement the Abuse Investigations Policy by allowing a CNA to continue resident care despite an allegation of physical abuse and not completing the investigation before the CNA returned to work.
Report Facts
Census: 63
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named as responsible for failure to implement Abuse Investigations Policy and incomplete investigation | |
| Wellness Director | Interviewed regarding the abuse allegation and involved in communication with CNA #1 | |
| CNA #1 | Certified Nursing Assistant | Alleged to have physically abused a resident; denied the allegation; was not reassigned or suspended pending investigation |
| CNA #2 | Certified Nursing Assistant | Worked with CNA #1 on the night of the alleged incident and stated nothing happened |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Date: Nov 19, 2020
Visit Reason
The inspection was conducted as a complaint investigation combined with a COVID-19 Focused Infection Control Survey based on complaint NJ00138819.
Complaint Details
Complaint # NJ00138819 triggered the inspection. The complaint involved infection control practices during the COVID-19 pandemic. The facility was found not in compliance with infection control regulations based on this complaint.
Findings
The facility was found to be in substantial compliance with licensure standards but failed to comply with infection control regulations related to COVID-19. Deficiencies included improper screening of staff and visitors, failure to conduct exposure risk assessments for residents leaving for dialysis, and malfunctioning dishwasher temperature gauges.
Deficiencies (3)
Failed to properly screen staff and visitors for COVID-19 at the facility entrance, including lack of hand sanitizer availability and incomplete temperature logs.
Failed to conduct exposure risk assessments and implement quarantine or isolation protocols for residents frequently leaving the facility for dialysis, including lack of precaution signs and PPE outside resident rooms.
Dishwasher temperature gauges were not in working order, potentially compromising sterilization and disinfection processes.
Report Facts
Census: 58
Survey Dates: 3
Dishwasher Temperature: 190
Dishwasher Temperature: 160
Dishwasher Rinse Cycle Temperature: 116
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist 1 | Mentioned in relation to failure to properly screen visitors and staff for COVID-19 and documentation errors. | |
| Wellness Director | Wellness Director | Interviewed regarding screening procedures and resident isolation practices. |
| Nurse 1 | Interviewed about screening of mailman and mask usage. | |
| Dining Service Director | Dining Service Director | Interviewed about dishwasher temperature gauge malfunction. |
| Administrator | Administrator | Interviewed regarding directives for resident isolation and dishwasher maintenance. |
Viewing
Loading inspection reports...
