Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT INGLEMOOR, LLC
ENGLEWOOD, NJ · 62 certified beds · Last Life Safety survey March 13, 2025
CMS Certification Number 315349 · first certified February 1996
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed July 1, 2021 (change of ownership)from 333 GRAND AVENUE OPERATIONS LLC
Position within NJ
20 citations — more than 71% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to November 2026. This facility’s last Life Safety survey was March 2025. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
2 of the 20 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 5, 2021 | 2 |
| January 26, 2023 | 4 |
| March 13, 2025 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | 2 | 2023-01-26 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-01-26 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2021-05-05 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-03-13 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 1 | 2025-03-13 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2025-03-13 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2025-03-13 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2023-01-26 |
What the citations cover
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 4
- Egress Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 13, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (April 11, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 28, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 11, 2025) |
January 26, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 15, 2023) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (March 15, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 15, 2023) |
| K-0781 | Have restrictions on the use of portable space heaters. | Waiver has been granted (March 15, 2023) |
May 5, 2021 — 2 citations
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.