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.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362GeneralS&S Fpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0531GeneralS&S Fpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0712GeneralS&S Fpotential for harm
Have simulated fire drills held at unexpected times.
- 0921GeneralS&S Fpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0225GeneralS&S Fpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0912GeneralS&S Fpotential for harm
Have power receptacles that are properly grounded.
- 0918GeneralS&S Fpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0919GeneralS&S Fpotential for harm
Meet requirements for the use of electrical equipment.
- 0920GeneralS&S Fpotential for harm
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 21, 2025 survey of COMPLETE CARE AT WEST CALDWELL LLC?
This was a inspection survey of COMPLETE CARE AT WEST CALDWELL LLC on March 21, 2025. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COMPLETE CARE AT WEST CALDWELL LLC on March 21, 2025?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install emergency lighting that can last at least 1 1/2 hours."
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.