Complete Care at Westfield, LLC

Inspectors wroteCOMPLAINT# NJ00174720 Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to submit a report to the New Jersey Department of Health (NJDOH) within the two-hour timeframe for an allegation of abuse against Certified Nursing Assistants (CNA) for two (2) of two (2) residents (Resident #61 and #241) reviewed for abuse reporting. The deficient practice was evidenced by the following: 1. On 2/28/25 at 11:00 AM, the surveyor observed Resident #61, in the dementia care activity room, seated in a wheelchair at a table with tablemates, flipping through a magazine. The resident said hello and smiled at the surveyor. On 3/3/24 at 12:50 PM, the surveyor observed Resident #61, in the dining room, awaiting lunch. The surveyor attempted to interview the resident, but the resident was unable to answer questions. [...]

Inspectors wroteBased on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to ensure heel booties were consistently applied to prevent skin breakdown. This deficient practice was identified for 1 of 4 residents (Resident #241) reviewed for position and mobility. This deficient practice was evidenced by the following: On 2/28/25 at 11:41 AM, during initial tour, the surveyor observed Resident #241 in bed dressed, lying on a mechanical lift pad. The resident was wearing socks. The resident stated they were waiting to go to therapy, which was usually around lunch time The surveyor reviewed the electronic medical record (EMR) for Resident # 241. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice by not appropriately assessing, monitoring, and documenting PRN (as needed) pain medications. This deficient practice was identified for 1 of 1 resident (Resident #241) reviewed for pain management. This deficient practice was evidence by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteComplaint # NJ166824 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for 1 of 35 residents (Resident #14) interviewed during the initial pool process and confirmed during the lunchtime meal service on 3/6/25 on 1 of 5 nursing units tested for food temperatures by the surveyor and witnessed by the Director of Nursing. The deficient practice was evidenced by the following: On 2/28/25 at 12:13 PM, the surveyor observed Resident #14 in their room. At that time, the resident stated that the food was cold. The surveyor reviewed the electronic medical record (EMR) for Resident #14. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP)(designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 1 of 3 unsampled residents (Resident #95) reviewed for EBP on 1 of 2 units ([NAME] Unit) and was evidenced by the following: On 3/04/25 at 08:10 AM, during incontinence rounds with the Unit Manager (UM) on the [NAME] Unit, the surveyor observed the UM approach unsampled Resident #95, who was lying in bed. The UM donned (put on) gloves and asked permission to check the resident's brief; [...]

Inspectors wroteComplaint #'s: NJ00167278, NJ0161406 Based on observation, interview, and review of the facility policy, the facility failed to provide proper tracheostomy care that included cleaning the skin around the stoma and cleaning the outer cannula and flange [neck plate] in accordance with professional standards for three of seven residents (Resident (R) 23, R33, and R34) reviewed for care. This failure could lead to stoma and lungs infections.

Inspectors wroteComplaint #: NJ00182358, NJ00169293 Based on interview, record review, and policy review, the facility failed to provide evidence that two of two residents (Resident (R) 5 and R30) reviewed for room transfers in a total sample of 34 residents were notified of the reason in writing for the transfer and when the transfer would occur prior to being transferred to another room in the facility. This failure had the potential to impact the emotional well-being of the residents facing the challenge of a new roommate.

Inspectors wroteComplaint #: NJ00182358, NJ00169293 Based on observation, record review, and staff interview, the facility failed to ensure residents who were being discharged to another facility were provided with a 30-day notice of discharge and to notify the Ombudsman's office for two residents (Residents (R) 14 and R15) of three residents reviewed for resident discharge. Failure to notify residents causes stress for the resident and family and impacts the residents' ability to prepare for discharge and have a choice in discharge location.

Inspectors wroteComplaint #: NJ00169314 Based on observation, interview, and review of the facility policy, the facility failed to identify and manage pain for one of 34 residents (Resident (R) 34) reviewed for pain. This failure could lead to reduced quality of life, depression and anxiety, and sleep disturbances.

Inspectors wroteComplaint #: NJ00172868 Based on observations, record review, interview, and facility policy review, the facility failed to ensure one out of three residents (Resident (R) 17) reviewed for side rails had interventions attempted prior to the implementation of side rails. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on her bed.

Inspectors wroteComplaint # NJ00160796, # NJ00160907 Based on observation, interview, review of facility records, and other pertinent facility documents on [DATE], it was determined that the facility failed to address a new aggressive behavior displayed on [DATE] and [DATE] by a resident who, within weeks of the new aggressive behavior, assaulted their roommate on [DATE] at 5:07 AM as the roommate slept in their bed. As a result of the assault, the roommate sustained the following injuries, according to the hospital records: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that nursing staff failed to ensure a) each prescription medication had a pharmacy label affixed with the resident's name and prescribing information; b) medication containers were labeled with the open date; c) an expired biological was removed from active inventory for an unsampled resident (Resident #141); d) expired medications were removed from active inventory. The deficient practice was observed in 4 of 4 nursing units and evidenced by the following. 1. On 02/03/23 at 1:35 PM the surveyor inspected the [NAME] Unit Medication Cart #2 in the presence of the unit Registered Nurse (RN #1). The surveyor observed 2 unopened 2 ml. vials of Ondansetron (Zofran) 4 mg/2 ml. The vials did not have pharmacy labels or dispensing bags. [...]

Inspectors wroteComplaint NJ# 00160615, 00160518 Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for failure to properly wear personal protective equipment. The deficient practices were evidenced by the following: On 1/30/23 at 11:00 AM, the surveyor observed the facility's Social Worker (SW) in the foyer near the receptionist with her N95 mask not covering her nose or mouth and there were three resident's present in the foyer at this time. At 11:05 AM, the surveyor interviewed the SW, who stated that she should have been wearing the N95 mask over her nose and mouth in the foyer and in all resident areas. [...]

Inspectors wroteComplaint # NJ00158684 Based on interviews conducted during the 2/6/23 Resident Council Meeting and 2 additional resident representative interviews and review of facility documentation it was determined the facility failed to provide care and services in a dignified and respectful manner. The concern was evidenced by the following. On 2/6/23, the surveyor reviewed Resident Council meeting minutes for past meetings. The 6/2022 minutes noted resident complaints of staff speaking on their cell phones while in the nursing unit. On 2/6/23 at 10:30 AM, the surveyor conducted the Resident Council Facility Task group meeting with 5 alert and oriented residents who were selected for participation by the facility. Five of 5 residents stated they had seen nursing department staff members talking on cell phones while in resident care areas. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care, Resident #36. This deficient practice was evidenced by the following: 1. On [DATE] at 11:00, the surveyor spoke with Resident #36 who stated she had lived there for about a year and used at electronic handheld device to communicate with the surveyor. The resident expressed concerns about her tracheostomy care. On [DATE] at 9:11 AM, the surveyor began the observation of tracheostomy care (tracheal care) by the Licensed Practical Nurse (LPN) for Resident #36. At 9:30 AM, the surveyor observed the LPN prepare her supplies that included, Tracheostomy Clean and Care kit that contained the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 2/9/23, the surveyor observed four nurses administer medications to six residents. There were 29 opportunities, and two errors were observed which resulted in a medication error rate of 6.9%. This deficient practice was identified for one of six residents, that was administered by one of four nurses. This deficient practice was evidenced by the following: On 2/7/23 at 8:47 AM, the surveyor observed the Certified Nurse Assistant (CNA) inform the Licensed Practical Nurse (LPN) that Resident #47 was in pain. At 8:55 AM, the surveyor observed the LPN prepare medications for Resident #47. The medications included the following: [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of foodborne illnesses; and, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. This deficient practice was observed and evidenced by the following: On 4/28/21 at 09:14 AM, the surveyors toured the kitchen in the presence of the Account Manager (AM) and observed the following: 1. The surveyor washed their hands at a handwashing station and observed the foot pedal did not open the lid to the trash can. The AM lifted the lid manually and stated he would get maintenance to look at it. 2. In the reach-in fridge, the AM removed one plate covered by a plastic bag and then another container covered by a plastic bag. [...]