Inspection visit
Inspection
Citations
15 citations recorded*CMS
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.
F726 - Nursing Services
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.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0886GeneralS&S Epotential for harm
Perform COVID19 testing on residents and staff.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0781GeneralS&S Fpotential for harm
Have restrictions on the use of portable space heaters.
FAQ · About this visit
Common questions about this visit
What happened during the January 26, 2023 survey of COMPLETE CARE AT INGLEMOOR, LLC?
This was a inspection survey of COMPLETE CARE AT INGLEMOOR, LLC on January 26, 2023. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at COMPLETE CARE AT INGLEMOOR, LLC on January 26, 2023?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes ..."
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.