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Public Record

Complete Care at Inglemoor, Llc

Nursing HomeEnglewood, NJCMS 315349
59 citations on record

From CMS

Facility profile

CMS overall rating
2 / 5

*CMS Five-Star

Certified beds
62

*CMS

Avg. residents per day
59.7

*CMS

Inspection record

On record from CMS

Citations on record
59

*CMS

Inspections on file
8

*CMS

Last inspection
2025-11-07

*CMS

Citations

59 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

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.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0225Generalpotential for harm

    Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0362Generalpotential for harm

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0531Generalpotential for harm

    Have elevators that firefighters can control in the event of a fire.

  • 0541Generalpotential for harm

    Install properly constructed and protected linen or trash chutes.

  • 0711Generalpotential for harm

    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

  • 0761Generalpotential for harm

    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.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0887Generalpotential for harm

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0578Generalpotential for harm

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  • 0623Generalpotential for harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0661Generalpotential for harm

    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0641Generalpotential for harm

    Ensure each resident receives an accurate assessment.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0041Generalpotential for harm

    Implement emergency and standby power systems.

  • 0223Generalpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0914Generalpotential for harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0921Generalpotential for harm

    Ensure that testing and maintenance of electrical equipment is performed.

  • 0603Generalpotential for harm

    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0726Generalpotential for harm

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  • 0732Generalpotential for harm

    Post nurse staffing information every day.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758Generalpotential for harm

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0814Generalpotential for harm

    Dispose of garbage and refuse properly.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0886Generalpotential for harm

    Perform COVID19 testing on residents and staff.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

  • 0781Generalpotential for harm

    Have restrictions on the use of portable space heaters.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0801Generalpotential for harm

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

  • 0761Generalpotential for harm

    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.

  • 0015Generalpotential for harm

    Address subsistence needs for staff and patients.

  • 0311Generalpotential for harm

    Have an enclosure around a vertical opening shaft.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0803Generalpotential for harm

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Complete Care at Inglemoor, Llc?
Complete Care at Inglemoor, Llc is a Medicare- and Medicaid-certified nursing home in Englewood, NJ, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 315349.
What is the CMS rating for Complete Care at Inglemoor, Llc?
Complete Care at Inglemoor, Llc has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Complete Care at Inglemoor, Llc have?
Complete Care at Inglemoor, Llc is certified for 62 beds. It serves an average of 59.7 residents per day.
How many citations does Complete Care at Inglemoor, Llc have?
Complete Care at Inglemoor, Llc has 59 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Complete Care at Inglemoor, Llc last inspected?
Complete Care at Inglemoor, Llc was last inspected on November 7, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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