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Complaint Investigation

Complete Care At Inglemoor, Llc

November 7, 2025 · Englewood, NJ · 333 Grand Ave
Citations 3
CMS Rating 2/5
Beds 62
Provider ID 315349
Healthcare Facility
Complete Care At Inglemoor, Llc
Englewood, NJ  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

COMPLETE CARE AT INGLEMOOR, LLC in ENGLEWOOD, NJ — inspection on November 7, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0580
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/07/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Inglemoor, LLC

333 Grand Ave Englewood, NJ 07631

SUMMARY STATEMENT OF DEFICIENCIES

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)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/07/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Inglemoor, LLC

333 Grand Ave Englewood, NJ 07631

SUMMARY STATEMENT OF DEFICIENCIES

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)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ENGLEWOOD, NJ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPLETE CARE AT INGLEMOOR, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.