Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Westfield, Llc during CMS and state inspections, most recent first.
Two residents experienced delayed reporting of abuse allegations by CNAs. One resident with dementia was allegedly yelled at, and the report was submitted late. Another resident, cognitively intact, reported being yelled at by CNAs after requesting assistance, with the incident reported the next day. Both cases showed failures in timely reporting to NJDOH.
A resident with multiple fractures and a care plan for skin integrity was found without prescribed heel booties during a survey. Despite a physician's order for their use, the resident confirmed they only wore socks. The facility's documentation did not reflect any refusal by the resident, and the DON acknowledged the lack of documentation and communication regarding the issue.
A facility failed to document PRN pain medication administration for a resident with multiple fractures, despite having a comprehensive care plan and physician orders. The pain flow sheet, intended to record pain characteristics and interventions, was left blank for several weeks. Interviews with staff revealed a lack of awareness about documentation requirements, highlighting a deficiency in meeting professional standards of practice.
A resident reported receiving cold food, and a survey confirmed that hot foods were served below safe temperatures, with Italian sausage at 116°F, spinach at 127°F, and noodles at 123.5°F. The facility's policy requires hot food to be served at or above 140°F. The resident had a history of bipolar disorder, GERD, anxiety, and obesity, with intact cognition.
A facility failed to ensure staff wore appropriate PPE for a resident on Enhanced Barrier Precautions (EBP), designed to reduce MDRO transmission. During an observation, a Unit Manager checked a resident's incontinence brief without wearing a gown, despite the EBP sign indicating the need for both gloves and a gown. The resident had Alzheimer's and a gastrostomy tube, requiring EBP. The Infection Preventionist confirmed the need for a gown during high-contact activities.
Nursing staff failed to clean the skin around the stoma, outer cannula, and flange during tracheostomy care for three residents with significant respiratory and neurological conditions. Staff acknowledged the omission, and facility policy requires these steps to be performed as part of routine tracheostomy care.
Two residents were moved to new rooms or received new roommates without being given written notice in advance, as required by facility policy. Documentation and staff interviews confirmed that written notifications were not provided prior to the room changes, affecting both a moderately cognitively impaired resident and a cognitively intact resident.
A resident with multiple chronic conditions and impaired cognition was not properly assessed for pain, despite exhibiting non-verbal cues and attempting to communicate discomfort. An LPN misinterpreted the resident's signals, did not allow adequate time for response, and failed to conduct a thorough pain assessment as required by facility policy before administering acetaminophen. The resident later reported experiencing daily pain for two weeks, particularly during urination, and indicated that pain assessments were not performed daily.
A resident with severe cognitive impairment and limited bed mobility was provided with side rails without documented attempts of less restrictive interventions, as required by facility policy. Staff interviews confirmed that alternatives were not tried or documented prior to side rail installation, resulting in a deficiency.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the New Jersey Department of Health (NJDOH) within the required two-hour timeframe. The first incident involved a resident with severe cognitive impairment due to dementia, who was allegedly yelled at by a CNA. The incident occurred in the morning, but the report was not submitted to the NJDOH until the following evening, well beyond the mandated reporting period. The Licensed Nursing Home Administrator at the time could not recall the reason for the delay, although she acknowledged that the incident should have been reported immediately. The second incident involved a cognitively intact resident who reported being yelled at by two CNAs after requesting assistance to return to bed. The resident had been left in a chair for an extended period and was not assisted back to bed until much later. The Director of Nursing was aware of the incident but did not report it to the NJDOH until the following day. The investigation into the incident was incomplete, lacking statements from key staff members, and the facility's response was delayed. Both incidents highlight a failure in the facility's procedures for timely reporting of abuse allegations. The facility's policy requires immediate reporting of such incidents, but in both cases, there was a significant delay. The facility's leadership acknowledged the reporting failures and the need for immediate action in such situations, but the deficiencies in reporting and investigation were evident.
Failure to Apply Heel Booties as Ordered
Penalty
Summary
The facility failed to ensure that heel booties were consistently applied to a resident to prevent skin breakdown. This deficiency was identified during a survey when a resident was observed in bed without the prescribed heel booties, despite having a physician's order for their use. The resident, who was cognitively intact, confirmed that they only wore socks and not the heel booties as required. The resident had been admitted with multiple fractures and was receiving physical and occupational therapy. Their care plan included interventions for potential skin integrity impairment, which specified the use of bilateral heel boots while in bed. However, during an incontinence round, the resident was found without the heel booties, and the CNA initially claimed the resident used them but later admitted they did not. The facility's documentation, including the Treatment Administration Records, indicated that the heel booties were administered, but there was no record of the resident refusing them. The Director of Nursing acknowledged the issue, stating that if the resident refused the booties, it should have been documented, and the physician and wound care team should have been informed. The facility's policy required adaptive devices to be applied as ordered, but this was not adhered to in this case.
Failure to Document PRN Pain Medication Administration
Penalty
Summary
The facility failed to meet professional standards of practice by not appropriately assessing, monitoring, and documenting PRN pain medications for a resident. This deficiency was identified during a survey when a resident, who was cognitively intact and receiving physical and occupational therapy, was observed in bed and reported having received pain medication. The resident had a history of multiple fractures and was on a pain management regimen that included Tramadol and Acetaminophen. The review of the resident's medical records revealed that the facility did not document the required pain flow sheet with each PRN pain medication administration from February 11 to March 4. The pain flow sheet was intended to document the characteristics, frequency, and non-medical interventions related to the resident's pain, as well as any side effects following the administration of PRN pain medication. Despite the presence of physician orders and a comprehensive care plan focusing on pain management, the documentation was consistently left blank. Interviews with facility staff, including an LPN and the DON, confirmed the lack of awareness and understanding regarding the documentation requirements for PRN pain medication administration. The DON acknowledged that the pain flow sheet was meant to provide detailed information about the resident's pain and should have been completed whenever PRN pain medication was administered. The facility's policy on pain management emphasized the importance of using a pain assessment tool to ensure consistent assessment and documentation of a resident's pain, which was not adhered to in this case.
Deficient Food Temperature Management
Penalty
Summary
The facility failed to ensure that hot foods served to residents were at safe and appetizing temperatures, as evidenced by the experience of a resident who reported receiving cold food. During the survey, the surveyor observed that the food temperatures on a test tray were below the required standards, with Italian sausage at 116 degrees F, sautéed spinach with garlic at 127 degrees F, and Parmesan noodles at 123.5 degrees F. These temperatures were confirmed by the Director of Nursing (DON) and were below the facility's policy requirements for hot food to be served at or above 140 degrees F. The resident involved had a medical history that included bipolar disorder, gastro-esophageal reflux disease, anxiety disorder, and obesity. The resident's cognition was intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The Food Service District Manager (FSDM) and Assistant Food Service Director (AFSD) acknowledged the inadequate food temperatures and stated that the department conducted test tray audits. However, the temperatures recorded on the test tray did not meet the facility's standards, indicating a deficiency in maintaining food quality and palatability.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to the Enhanced Barrier Precautions (EBP) policy, which is designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. During an observation, the Unit Manager (UM) was seen checking the incontinence brief of a resident on EBP without wearing the required gown, although gloves were used. The EBP sign outside the resident's room clearly indicated that both gloves and a gown were necessary for high-contact resident care activities, such as changing briefs or assisting with toileting. The UM acknowledged the oversight when questioned by the surveyor. The resident involved had a medical history that included Alzheimer's disease and a gastrostomy tube, which necessitated the use of EBP due to the potential for MDRO transmission. The facility's policy, implemented on 9/1/24, specified that gowns and gloves should be worn during high-contact activities for residents with indwelling medical devices, like feeding tubes, even if there are no secretions or excretions. The Infection Preventionist confirmed that the staff should have worn a gown in addition to gloves when performing direct contact activities with the resident.
Failure to Perform Complete Tracheostomy Care
Penalty
Summary
The facility failed to provide proper tracheostomy care for three residents who required this intervention, as observed during multiple care procedures. For each resident, nursing staff removed and discarded soiled split gauze from the stoma under the flange, changed gloves, and applied new split gauze, but did not clean the skin around the stoma, the outer cannula, or the flange as required by facility policy and professional standards. These actions were observed during tracheostomy care for residents with significant medical histories, including anoxic brain damage, chronic respiratory failure, and myasthenia gravis, all of whom had impaired cognition. Interviews with the involved nursing staff confirmed that they did not clean around the stoma during the procedures and acknowledged that this step should have been performed. The unit manager, ADON, and DON all stated that cleaning around the stoma and tracheostomy components is a required part of tracheostomy care, as reinforced during staff training. Review of the facility's tracheostomy care policy further confirmed that cleaning the area around the stoma and related parts is a required step in the procedure.
Failure to Provide Written Notice for Room Transfers
Penalty
Summary
The facility failed to provide written notice to two residents regarding room transfers, as required by policy and regulation. One resident, who was moderately cognitively impaired with a BIMS score of 9, was transferred to a new room without documented written notification of the move. Another resident, who was cognitively intact with a BIMS score of 14, did not receive written notice that a new roommate would be moving into their room. The records reviewed, including the electronic medical records and census lists, did not contain evidence of written notifications for either resident prior to the room changes. Interviews with facility staff confirmed that written notices were not located for the room transfers in question. The Social Services Director acknowledged the absence of written transfer notices for both residents and described the current process of discussing changes and documenting them in the clinical record, but could not provide evidence that this was done at the time of the transfers. The facility's policy requires advance written notice in a language and manner understood by the resident or representative, including the reason for the move, but this was not followed in these instances.
Failure to Identify and Manage Pain in Resident with Communication Impairment
Penalty
Summary
A resident with diagnoses including myasthenia gravis with acute exacerbation, cerebral palsy, and chronic respiratory failure with hypoxia, and who had moderately impaired cognition, was not properly assessed or managed for pain. The resident had an order for acetaminophen as needed for pain, to be administered via G-tube. During an observation, the resident attempted to communicate pain by shaking their hand and pointing to the groin area, but the LPN initially misinterpreted these cues as a need to urinate. After being prompted, the LPN provided a notebook, and the resident wrote 'pain.' The LPN asked about the pain but did not allow sufficient time for the resident to respond before offering medication. The LPN then administered acetaminophen. Further interview with the resident revealed that they experienced pain every day, specifically when urinating, and that the pain had been ongoing for two weeks. The resident indicated that nurses did not assess their pain daily. Staff interviews confirmed that pain monitoring was expected every shift and that non-verbal cues should be used for residents with communication difficulties. The facility's policy required thorough pain assessment, including identifying the location, duration, and characteristics of pain, but these steps were not fully followed in this case.
Failure to Attempt Less Restrictive Interventions Before Side Rail Use
Penalty
Summary
The facility failed to ensure that less restrictive interventions were attempted prior to the implementation of side rails for one resident. The resident, who was severely cognitively impaired with a BIMS score of 3 out of 15 and required substantial assistance for bed mobility, was admitted to the facility and subsequently had side rails installed and in use on her bed. Documentation showed that the risks and benefits of side rail use were discussed with the resident's representative and consent was obtained. The care plan indicated the use of side rails for safety during care and to assist with bed mobility, and a side rail assessment noted the resident could use the rails to move from side to side. However, interviews with facility staff, including a CNA, LPN, Director of Rehabilitation, and Director of Nursing, revealed that no prior interventions or less restrictive alternatives were attempted or documented before the use of side rails. The facility's policy required that less restrictive interventions, such as restorative care, use of a trapeze, lowering the bed, or using a soft mat, be tried and documented as unsuccessful before considering side rails. No evidence was provided that these steps were taken for this resident, resulting in a deficiency related to the improper implementation of side rails.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Clark Llc | 0.6 mi | ★★★★★ | 1 | 0 |
| Ashbrook Care & Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Care Connection Rahway | 2.4 mi | ★★★★★ | 12 | 0 |
| Cranford Park Care | 2.5 mi | ★★★★★ | 12 | 0 |
| Childrens Specialized Hospital Mountainside | 3.2 mi | ★★★★★ | 2 | 0 |
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