01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-13 | 19 | 2025-03-13 | 14 |
| Cycle 2 | 2023-01-26 | 12 | 2023-01-26 | 4 |
| Cycle 3 | 2021-05-05 | 8 | 2021-05-05 | 2 |
CMS CCN 3153492026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At Inglemoor, Llc
333 Grand Ave · Englewood, NJ 07631 · Bergen County
Certified beds62CMS provider file
Recent citation rows59current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
59 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 8 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-11-07 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-12-08 · complaint2025-11-07 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-12-17 · complaint2025-11-07 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-12-17 · complaint2025-03-13 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2025-04-152025-03-13 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-04-02 · complaint2025-03-13 · HEALTHF0623Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0661Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0711Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-04-11 · complaint2025-03-13 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · FIREK0223Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · FIREK0225Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2025-04-112025-03-13 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-04-152025-03-13 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-04-1503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PC NJ1 OPCOS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2021
- PC WTA OPCO HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/01/2021
- SMS 2021 TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 07/01/2021
- STEIN, SHALOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/01/2021
- WELLTOWER INCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2021
- GROSS, HARVEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/21/2021
- SCHWARTZ, HERSHELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/30/2021
- SINGER, IANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/03/2025
- ZACKAI, RAANANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2021
- STEIN, SHALOMIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2021
- AURORA GUARDIAN HOLDCO II CO-BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN HOLDCO II MEZZ BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN HOLDCO II, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN II REALTY, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN PARTNERS II LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- INGLEMOOR CENTER REALTY, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.59per resident day
RN hours0.64per resident day
Weekend nurse hours3.42per resident day
Staff turnover38.5%CMS reported field
06 / LOCAL RECORDS
Open the Englewood ledger →