Complete Care At Inglemoor, Llc

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

depression. The order was dc'd on 5/9/25. Date ordered 5/9/25, trazodone 150 mg, to give one tab by mouth at HS for mood disorder and insomnia. Date ordered 5/2/25, Depakote sprinkle 125 mg, give two capsules (caps) for total of 250 mg 3x/day (three times a day) for mood disorder. The order was dc'd on 5/4/25. Date ordered 5/4/25, Depakote sprinkle 125 mg, give three caps (375 mg) 3x/day. Date ordered 5/3/25, Seroquel 25 mg, give 1 tab by mouth every 8 hours for psychosis, hold dose for sedation. Date ordered 5/19/25, Ativan (also known as lorazepam) 0.5 mg, to give one tab by mouth every six hours PRN (as needed) for anxiety for 30 days. Further review of the above PN revealed that there was no documented evidence that EC #1 and EC #2 were notified of the change in resident's condition, when the resident was noted sedated, meds were held, lethargic, and there were changes in resident's meds. There were no documented evidence that the physician was notified of resident's changes in condition on 5/14/25, 5/15/25, 5/16/25, and 6/1/25. On 11/7/25 at 1:33 PM, the surveyors met with the Director of Nursing (DON), who informed the surveyor that any residents who had change in condition, including lethargy or sedation that was not in their norm, it was an expectation that the nurse would notify the RR and the physician, and documented in the PN. At that same time, the surveyor notified the DON of the above findings and concerns that there were no documented evidence that the RR and the physician were notified of the change in the condition of the resident. The surveyor also asked for the facility's policy with regard to notification of change in condition. A review of the facility's Notification of Changes Policy that was provided by the DON, with a date reviewed/revised of 9/1/25, revealed that the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the RR when there is a change requiring notification. Definitions:. clinical complications, examples.recurrent episodes of delirium. need to alter treatment significantly, means a need to stop a form of treatment because of adverse consequences, or commence a new form of treatment to deal with a problem. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the RR when there is a change requiring such notification. Circumstances requiring notification include:.2. Significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental or psychosocial status.3. Circumstances that require a need to alter treatment. This may include:a. New treatment.b. Discontinuation of current treatment due to adverse consequences, acute condition. On 11/7/25 at 2:51 PM, the surveyors met with the DON and the [NAME] President of Clinical Services, and there were no additional information provided by the DON. NJAC 8:39-4.1(a)2; 13.1 (c), (d)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Inglemoor, LLC

333 Grand Ave Englewood, NJ 07631

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm

the resident's re-admission to the facility. A review of the facility's Weight Monitoring Policy, dated 9/1/25, revealed under Compliance Guidelines: .5. A weight monitoring schedule will be developed upon admission for all residents: a. Newly admitted residents- Weight on admission and monitor weight weekly for four weeks b. If clinically indicated- monitor weight daily c. All others- monitor weight monthly . NJAC 8:39-11.2(b); 27.1(a)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Inglemoor, LLC

333 Grand Ave Englewood, NJ 07631

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm

information provided by the DON. The DON acknowledged that the resident's medical records of resident should be complete. There was no policy provided with regard to medical records. NJAC 8:39-35.2 (d)(5)(6)(e)(f)(k)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet