Inspection visit
Fire Safety inspection
Citations
16 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0001GeneralS&S Fpotential for harm
Establish an Emergency Preparedness Program (EP).
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0111GeneralS&S Epotential for harm
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
- 0222GeneralS&S Epotential for harm
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.
- 0281GeneralS&S Epotential for harm
Install proper backup exit lighting.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0347GeneralS&S Fpotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0901GeneralS&S Fpotential for harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
- 0911GeneralS&S Fpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0915GeneralS&S Fpotential for harm
Have proper power supply for life support equipment.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0921GeneralS&S Epotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0923GeneralS&S Epotential for harm
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the February 13, 2023 survey of COMPLETE CARE AT WESTFIELD, LLC?
This was a inspection survey of COMPLETE CARE AT WESTFIELD, LLC on February 13, 2023. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COMPLETE CARE AT WESTFIELD, LLC on February 13, 2023?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.