A list of the most recent deficiencies for Complete Care at Westfield, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-02-13 | 2023-03-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-13 | 2023-03-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-13 | 2023-03-21 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-02-13 | 2023-03-19 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-02-13 | 2023-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-13 | 2023-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-13 | 2023-03-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-13 | 2023-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-13 | 2023-03-08 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-13 | 2023-02-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-13 | 2023-02-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-13 | 2023-02-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-02-13 | 2023-02-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-02-13 | 2023-02-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-13 | 2023-02-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-13 | 2023-02-24 | N |
| 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. | Fire Safety | 2023-02-13 | 2023-02-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-13 | 2023-02-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-13 | 2023-02-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-13 | 2023-02-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-13 | 2023-02-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-13 | 2023-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-14 | 2022-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-22 | 2022-05-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-22 | 2022-05-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-06 | 2021-06-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-06 | 2021-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-06 | 2021-05-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-06 | 2021-05-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-28 | 2019-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-28 | 2019-08-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-28 | 2019-08-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-28 | 2019-08-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-28 | 2019-08-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-28 | 2019-08-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-28 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-28 | 2019-08-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-06-28 | 2019-08-15 | N |
