Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT WESTFIELD, LLC
WESTFIELD, NJ · 227 certified beds · Last Life Safety survey March 10, 2025
CMS Certification Number 315122 · first certified November 1970
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed July 1, 2021 (change of ownership)from 1515 LAMBERTS MILL ROAD OPERATIONS LLC
Position within NJ
30 citations — more than 94% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 11 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: June 2026 to November 2026. This facility’s last Life Safety survey was March 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about COMPLETE CARE AT WESTFIELD, LLC
One email when it happens. No account; stop it any time with one click.
1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 30 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 30 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 30 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 6, 2021 | 3 |
| February 13, 2023 | 16 |
| March 10, 2025 | 11 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2025-03-10 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2023-02-13 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 2 | 2025-03-10 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2023-02-13 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-03-10 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2023-02-13 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2023-02-13 |
| K-0915 | Have proper power supply for life support equipment. | 1 | 2023-02-13 |
What the citations cover
- Smoke Deficiencies 11
- Egress Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Emergency Preparedness Deficiencies 4
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Egress Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 4 |
| Construction Deficiencies | 1 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 10, 2025 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (April 7, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 4, 2025) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (April 4, 2025) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 28, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 11, 2025) |
February 13, 2023 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 28, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (February 28, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (February 28, 2023) |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (March 28, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (February 19, 2023) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (March 9, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 24, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 13, 2023) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (February 28, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 21, 2023) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Waiver has been granted (March 19, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (February 24, 2023) |
| K-0915 | Have proper power supply for life support equipment. | Waiver has been granted (March 19, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 8, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (February 24, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (February 24, 2023) |
May 6, 2021 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (May 10, 2021) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 18, 2021) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 31, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.