Complete Care at Inglemoor, LLC
333 Grand Ave, Englewood, NJ 07631
Complete Care at Inglemoor, LLC is a nursing home in Englewood, New Jersey. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (201) 568-0900
- Last standard health inspection
- March 13, 2025 (1 year ago)
- Certified beds
- 62
- Residents per day, on average
- 58.5
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Complete Care at Inglemoor LLC
- Chain
- Complete Care
- Takes part in
- Medicare and Medicaid
More health citations than the New Jersey average (39 vs 24).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
3 citations
Health inspection on November 7, 2025
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on December 8, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on December 17, 2025.
CMS has cited this home for F0692 2 times since 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on December 17, 2025.
CMS has cited this home for F0842 2 times since 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
CMS update of March 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
16 citations
Health inspection on March 13, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for F0812 3 times since 2021.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for F0658 2 times since 2021.
Citation F0711. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
CMS lists it as corrected on April 11, 2025.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 11, 2025.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on April 11, 2025.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 11, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 2, 2025.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on April 11, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on April 11, 2025.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on April 11, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 11, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 11, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 11, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 11, 2025.
CMS has cited this home for F0761 2 times since 2021.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 11, 2025.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 11, 2025.
14 citations
Fire safety inspection on March 13, 2025
CMS lists this as a standard inspection.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on April 15, 2025.
Citation K0223. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on April 11, 2025.
Citation K0225. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on April 11, 2025.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 15, 2025.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 15, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 15, 2025.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on April 15, 2025.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on April 15, 2025.
Citation K0531. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have elevators that firefighters can control in the event of a fire.
CMS lists it as corrected on April 15, 2025.
Citation K0541. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on April 11, 2025.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on April 28, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 15, 2025.
Citation K0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that testing and maintenance of electrical equipment is performed.
CMS lists it as corrected on April 15, 2025.
Citation K0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on April 11, 2025.
1 citation
Health inspection on December 3, 2024
CMS lists this as a complaint inspection.
Citation F0603. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
CMS lists it as corrected on December 4, 2024.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
11 citations
Health inspection on January 26, 2023
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 15, 2023.
CMS has cited this home for F0880 2 times since 2021.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 15, 2023.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on March 15, 2023.
CMS has cited this home for F0756 2 times since 2021.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 15, 2023.
Citation F0886. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Perform COVID19 testing on residents and staff.
CMS lists it as corrected on March 15, 2023.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 15, 2023.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on March 15, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 15, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 15, 2023.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 15, 2023.
Citation F0814. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on March 15, 2023.
4 citations
Fire safety inspection on January 26, 2023
CMS lists this as a standard inspection.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on March 15, 2023.
Citation K0311. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on March 15, 2023.
CMS has cited this home for K0311 2 times since 2021.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on March 15, 2023.
Citation K0781. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on March 15, 2023.
8 citations
Health inspection on May 5, 2021
CMS lists this as a standard inspection.
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on June 11, 2021.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 11, 2021.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on June 11, 2021.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 11, 2021.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 27, 2021.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on June 11, 2021.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on June 11, 2021.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 11, 2021.
2 citations
Fire safety inspection on May 5, 2021
CMS lists this as a standard inspection.
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on July 27, 2021.
Citation K0311. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on June 11, 2021.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- PC NJ1 OPCOS LLC5% or greater direct ownership interest · 100% · since 07/01/2021
- PC WTA OPCO HOLDCO LLC5% or greater indirect ownership interest · no percentage provided · since 07/01/2021
- SMS 2021 TRUST5% or greater indirect ownership interest · no percentage provided · since 07/01/2021
- STEIN, SHALOMIndirect ownership interest · not applicable · since 07/01/2021
- GROSS, HARVEYOperational/managerial control · not applicable · since 07/21/2021
- SCHWARTZ, HERSHELOperational/managerial control · not applicable · since 07/30/2021
- SINGER, IANOperational/managerial control · not applicable · since 03/03/2025
- ZACKAI, RAANANOperational/managerial control · not applicable · since 07/01/2021
Questions
When was Complete Care at Inglemoor, LLC last inspected?
CMS lists March 13, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Complete Care at Inglemoor, LLC have?
CMS lists 39 health citations since May 5, 2021. CMS also calls these deficiencies.
Has Complete Care at Inglemoor, LLC been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Complete Care at Inglemoor, LLC?
Its CMS overall star rating is 2 of 5.
Is Complete Care at Inglemoor, LLC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.