Complete Care at Inglemoor: Notification Failures - NJ
That is what federal inspectors found when they arrived at the facility at 333 Grand Ave on November 7, 2025.
The medication history alone tells a story of rapid, repeated adjustment. In early May 2025, the resident was placed on Depakote sprinkle 125 mg, two capsules three times a day, for mood disorder. Two days later, that order was discontinued. A new Depakote order came the same day it was stopped, this time at a higher dose, three capsules three times a day. Seroquel, an antipsychotic, was added on May 3rd. An antidepressant, trazodone 150 mg at bedtime, was ordered May 9th, the same day a prior depression medication was discontinued. By May 19th, Ativan, a benzodiazepine used for anxiety, had been added on an as-needed basis, up to every six hours.
Somewhere in the middle of all that, the resident became sedated. Doses were held. The resident was described as lethargic. These are not subtle developments in a person on multiple psychiatric medications, some of which carry sedation as a known consequence serious enough that the Seroquel order itself included an instruction to hold the dose for sedation.
On May 14th, May 15th, May 16th, and again on June 1st, there was no documented evidence that the physician was notified of the resident's changes in condition. Inspectors also found no documentation that the emergency contact, identified in the report as EC #1 and EC #2, was reached on any of those days, or when the sedation was first observed, or when medications were being held.
When inspectors sat down with the Director of Nursing that afternoon, she was direct about what the expectation was. Any resident with a change in condition, including lethargy or sedation outside their normal baseline, should trigger a call to the responsible party and the physician, and that call should be documented in the nursing notes. That was the standard. She said so herself.
The facility's own written policy, reviewed and revised as recently as September 1, 2025, two months before the inspection, spelled out the same obligation. It listed significant changes in a resident's physical, mental, or psychological condition as circumstances requiring notification. It specifically named the need to alter treatment, including stopping a medication due to adverse consequences, as a trigger. Stopping Depakote after two days, holding Seroquel doses for sedation, those are exactly the kinds of events the policy was written to capture.
None of it was documented as having happened.
The Director of Nursing and the President of Clinical Services met again with inspectors at 2:51 that afternoon. No additional information was provided.
What the record shows is a resident whose medication regimen shifted five times in roughly three weeks, who became sedated in the middle of those changes, and whose family and doctor, by the available documentation, were not told. The facility knew what was required. It had written it down. The gap between the policy on paper and what the nurses actually recorded on those four days in May and one day in June is what inspectors came to document, and did.
The resident's condition after those days of unreported lethargy, and whether the sedation resolved or persisted, is not reflected in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Inglemoor, LLC from 2025-11-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
COMPLETE CARE AT INGLEMOOR, LLC in ENGLEWOOD, NJ was cited for violations during a health inspection on November 7, 2025.
That is what federal inspectors found when they arrived at the facility at 333 Grand Ave on November 7, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.