Nursing Care Index

Complete Care At Inglemoor, LLC

Englewood, Bergen County, New Jersey · CCN 315349 · For-profit (LLC) · part of Complete Care (85 facilities, chain average 3.1 stars)

CMS rates Complete Care At Inglemoor, LLC 2 of 5 overall as of August 2026. 62 certified beds, 59 residents a day on average. 39 citations on record from the current inspection cycles; no fines on record.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★☆☆☆ 2 of 5
Health inspections★★☆☆☆ 2 of 5
Staffing★★★☆☆ 3 of 5
Quality measures★★★☆☆ 3 of 5
Quality: long-stay / short-stay4 / 2 of 5

Staffing

Total nurse staffing3.59447 hours per resident per day
Registered nurses0.64107 hours per resident per day
Weekend total3.41941 hours per resident per day
Nursing staff turnover38.5% (registered nurses 44.4%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2025-11-07
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-08
2025-11-07
complaint survey
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-17
2025-11-07
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-04-11
2025-03-13 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
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.
Nursing and Physician Services Deficiencies · tag F0711
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-11
2025-03-13
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-11
2025-03-13 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Resident Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2025-03-13
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Resident Rights Deficiencies · tag F0623
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2025-03-13 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Resident Assessment and Care Planning Deficiencies · tag F0661
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2025-03-13 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2025-03-13 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2025-03-13 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2025-03-13 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · tag F0883
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Infection Control Deficiencies · tag F0887
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2024-12-03
complaint survey
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0603
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-04
2023-01-26 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
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.
Resident Assessment and Care Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
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.
Pharmacy Service Deficiencies · tag F0756
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
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.
Pharmacy Service Deficiencies · tag F0758
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-03-15
2023-01-26 Perform COVID19 testing on residents and staff.
Infection Control Deficiencies · tag F0886
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
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.
Nursing and Physician Services Deficiencies · tag F0726
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-03-15
2023-01-26 Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · tag F0732
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-03-15
2023-01-26 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Nutrition and Dietary Deficiencies · tag F0812
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-03-15
2023-01-26 Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies · tag F0814
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Nutrition and Dietary Deficiencies · tag F0801
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
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.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
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.
Pharmacy Service Deficiencies · tag F0756
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
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.
Nutrition and Dietary Deficiencies · tag F0803
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2021-06-11
2021-05-05 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2021-07-27
2021-05-05 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2021-06-11
2021-05-05 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
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.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2021-06-11

Fines and payment denials

No fines or payment denials on record since 2023.

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
PC Nj1 Opcos LLC
Organization
5% or greater direct ownership interest100%2021-07-01
PC Wta Opco Holdco LLC
Organization
5% or greater indirect ownership interest2021-07-01
Sms 2021 Trust
Organization
5% or greater indirect ownership interest2021-07-01
Welltower Inc.
Organization
5% or greater security interest2021-07-01
Aurora Guardian Holdco II Co-Borrower, LLC
Organization
adp of the snf2021-07-30
Aurora Guardian Holdco II Mezz Borrower, LLC
Organization
adp of the snf2021-07-30
Aurora Guardian Holdco II, LLC
Organization
adp of the snf2021-07-30
Aurora Guardian II Realty, LLC
Organization
adp of the snf2021-07-30
Aurora Guardian Partners II LLC
Organization
adp of the snf2021-07-30
Inglemoor Center Realty, LLC
Organization
adp of the snf2021-07-30
J & R Family Investments, LLC
Organization
adp of the snf2021-07-30
L Friedman 2018 Family Trust
Organization
adp of the snf2021-07-30
L Friedman Family Holdings LLC
Organization
adp of the snf2021-07-30
Landau Family Investment Trust
Organization
adp of the snf2021-07-30
M Friedman 2018 Family Trust
Organization
adp of the snf2021-07-30
PC Wta Acquisition LLC
Organization
adp of the snf2021-07-01
PC Wta Multi-State LLC
Organization
adp of the snf2021-07-01
Peace Capital Holdings LLC
Organization
adp of the snf2021-07-01
R&J Family Investments LLC
Organization
adp of the snf2021-07-30
Sms 2021 Trust
Organization
adp of the snf2021-07-01
Welltower Inc.
Organization
adp of the snf2021-07-01
Fiegle, Margaret
Individual
adp of the snf2023-04-10
Gross, Harvey
Individual
adp of the snf2021-07-21
Singer, Ian
Individual
adp of the snf2025-03-03
Stein, Shalom
Individual
corporate officer2021-07-01
Stein, Shalom
Individual
indirect ownership interest2021-07-01
Stein, Shalom
Individual
managing control - governing body2021-07-01
Gross, Harvey
Individual
operational/managerial control2021-07-21
Schwartz, Hershel
Individual
operational/managerial control2021-07-30
Singer, Ian
Individual
operational/managerial control2025-03-03
Zackai, Raanan
Individual
operational/managerial control2021-07-01
Stein, Shalom
Individual
trustee of the snf2021-07-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Bergen County.