Complete Care at Inglemoor, LLC

CMS star ratings

Overall★★★★★ 2/5

State avg 3.3

Health inspections★★★★★ 2/5

State avg 2.8

Staffing★★★★★ 3/5

State avg 3.0

Quality measures★★★★★ 3/5

State avg 4.4

Long-stay quality★★★★★ 4/5

Short-stay quality★★★★★ 2/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing: 3.59 (state 3.85 · U.S. 3.86)
Registered nurses (RN): 0.64 (state 0.68 · U.S. 0.69)
Licensed practical nurses: 0.80 (state 0.93 · U.S. 0.86)
Nurse aides: 2.15 (state 2.23 · U.S. 2.32)
Weekend total: 3.42 (state 3.50 · U.S. 3.42)
Nursing staff turnover: 38.5 (state 39.7 · U.S. 45.8)%
RN turnover: 44.4 (state 37.7 · U.S. 42.9)%
Administrators who left: 0 in the last year

Inspections

Last standard inspection: March 13, 2025
Health deficiencies (last cycle): 19.0 (state 8.8 · U.S. 9.3)
From complaints: 5
Citations on record (3 years): 39 health · 20 fire safety

Date	Citation	Severity	Status
2025-11-07	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580 · Resident Rights Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2025-12-08
2025-11-07	Provide enough food/fluids to maintain a resident's health. F0692 · Quality of Life and Care Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2025-12-17
2025-11-07	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2025-12-17
2025-03-13	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Ensure services provided by the nursing facility meet professional standards of quality. F0658 · Resident Assessment and Care Planning Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. F0711 · Nursing and Physician Services Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection	E No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	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. F0578 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Respond appropriately to all alleged violations. F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2025-04-02
2025-03-13	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. F0623 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Ensure each resident receives an accurate assessment. F0641 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. F0661 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Provide enough food/fluids to maintain a resident's health. F0692 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Provide safe and appropriate respiratory care for a resident when needed. F0695 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2025-03-13	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. F0887 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2025-04-11
2024-12-03	Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). F0603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection	D No actual harm, potential for more than minimal harm	Corrected 2024-12-04
2023-01-26	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. F0756 · Pharmacy Service Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	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. F0758 · Pharmacy Service Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Perform COVID19 testing on residents and staff. F0886 · Infection Control Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	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. F0726 · Nursing and Physician Services Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Post nurse staffing information every day. F0732 · Nursing and Physician Services Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Ensure medication error rates are not 5 percent or greater. F0759 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2023-01-26	Dispose of garbage and refuse properly. F0814 · Nutrition and Dietary Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2023-03-15
2021-05-05	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. F0801 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2021-06-11
2021-05-05	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies	F No actual harm, potential for more than minimal harm	Corrected 2021-06-11
2021-05-05	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. F0756 · Pharmacy Service Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2021-06-11
2021-05-05	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. F0803 · Nutrition and Dietary Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2021-06-11
2021-05-05	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2021-07-27
2021-05-05	Implement a program that monitors antibiotic use. F0881 · Infection Control Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2021-06-11
2021-05-05	Ensure services provided by the nursing facility meet professional standards of quality. F0658 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-06-11
2021-05-05	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-06-11

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

Name	Role	Since
PC NJ1 Opcos LLC (organization)	5%+ Direct Ownership Interest · 100%
PC Wta Opco Holdco LLC (organization)	5%+ Indirect Ownership Interest
SMS 2021 Trust (organization)	5%+ Indirect Ownership Interest
Welltower INC (organization)	5%+ Security Interest · NOT APPLICABLE
Aurora Guardian Holdco II Co-Borrower, LLC (organization)	Administrator · NOT APPLICABLE
Aurora Guardian Holdco II Mezz Borrower, LLC (organization)	Administrator · NOT APPLICABLE
Aurora Guardian Holdco II, LLC (organization)	Administrator · NOT APPLICABLE
Aurora Guardian II Realty, LLC (organization)	Administrator · NOT APPLICABLE
Aurora Guardian Partners II LLC (organization)	Administrator · NOT APPLICABLE
Fiegle, Margaret (individual)	Administrator · NOT APPLICABLE
Gross, Harvey (individual)	Administrator · NOT APPLICABLE
Inglemoor Center Realty, LLC (organization)	Administrator · NOT APPLICABLE
J & R Family Investments, LLC (organization)	Administrator · NOT APPLICABLE
L Friedman 2018 Family Trust (organization)	Administrator · NOT APPLICABLE
L Friedman Family Holdings LLC (organization)	Administrator · NOT APPLICABLE
Landau Family Investment Trust (organization)	Administrator · NOT APPLICABLE
M Friedman 2018 Family Trust (organization)	Administrator · NOT APPLICABLE
PC Wta Acquisition LLC (organization)	Administrator · NOT APPLICABLE
PC Wta Multi-State LLC (organization)	Administrator · NOT APPLICABLE
Peace Capital Holdings LLC (organization)	Administrator · NOT APPLICABLE
R&J Family Investments LLC (organization)	Administrator · NOT APPLICABLE
Singer, Ian (individual)	Administrator · NOT APPLICABLE
SMS 2021 Trust (organization)	Administrator · NOT APPLICABLE
Welltower INC (organization)	Administrator · NOT APPLICABLE
Stein, Shalom (individual)	Corporate Officer · NOT APPLICABLE
Stein, Shalom (individual)	Indirect Ownership Interest · NOT APPLICABLE
Stein, Shalom (individual)	Managing Control - Governing Body · NOT APPLICABLE
Gross, Harvey (individual)	Operational/managerial Control · NOT APPLICABLE
Schwartz, Hershel (individual)	Operational/managerial Control · NOT APPLICABLE
Singer, Ian (individual)	Operational/managerial Control · NOT APPLICABLE
Zackai, Raanan (individual)	Operational/managerial Control · NOT APPLICABLE
Stein, Shalom (individual)	Trustee Of The Snf · NOT APPLICABLE

Frequently asked questions

What is the rating of Complete Care at Inglemoor, LLC?

Complete Care at Inglemoor, LLC has a 2-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.3-star average in New Jersey.

How many beds does Complete Care at Inglemoor, LLC have?

It has 62 certified beds and cares for about 59 residents per day.

Has Complete Care at Inglemoor, LLC been fined?

CMS lists no federal fines or payment denials in the last three years.

Who owns Complete Care at Inglemoor, LLC?

It is part of Complete Care and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Complete Care at Inglemoor, LLC?

(201) 568-0900. The facility is located at 333 Grand Ave, Englewood, NJ 07631.

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Contact & location

Facility details