Inspection Reports for
Complete Care At Inglemoor, Llc

Complaint #402154 and Complaint #NJ187551 involved failure to notify physician and resident's representatives of changes in condition, failure to ensure weight monitoring per physician orders, and incomplete medical records for Resident #1. The complaints were substantiated based on interviews, record reviews, and facility document reviews.

The facility was found deficient in notifying the physician and resident's representatives of changes in condition, failing to ensure adequate weight monitoring and nutrition per physician orders, and maintaining incomplete medical records for Resident #1. These deficiencies were supported by review of medical records, interviews, and facility policies.

Complaint NJ#161311 involved an allegation of abuse where Resident #310 sustained a 1 cm cut to the left eyebrow caused by an overbed table. The investigation was incomplete with missing individual statements and documentation. Complaint NJ#179968 and NJ#181921 involved failure to maintain accurate and complete medical records for multiple residents, with missing documentation related to Facility Reported Events.

The facility failed to conduct a thorough investigation into an allegation of abuse involving Resident #310, lacking comprehensive documentation and individual statements. Additionally, the facility failed to maintain complete, accurate, and readily accessible medical records for 5 of 18 residents reviewed, with discrepancies and missing documentation related to Facility Reported Events (FRE).

Complaint NJ#161311 related to failure to conduct thorough abuse investigation; substantiation status not explicitly stated.

The inspection identified multiple deficiencies including failure to keep call bell within reach for a resident, inaccurate documentation of advance directives, incomplete abuse investigation, failure to provide timely transfer notifications, inaccurate MDS coding, medication order clarifications needed, medication availability issues, incomplete physician reviews, improper medication storage, inadequate kitchen sanitation, failure to offer and document vaccinations, and incomplete medical records.

Complaint #NJ00180296 was substantiated. The facility failed to prevent involuntary seclusion of Resident #1 by a nurse during the night shift on 12/03/2024. The nurse was suspended pending investigation and later terminated. Staff were in-serviced on abuse and involuntary seclusion policies.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to ensure a resident was free from involuntary seclusion. The investigation revealed that a nurse confined a resident in their room against their will during a night shift. The nurse was terminated and staff received training on abuse and involuntary seclusion policies.

Complaint # NJ00180296 regarding involuntary confinement of Resident #1 by a nurse on 09/18/2024. The nurse closed the resident's door to prevent wandering, which was reported by another resident. The nurse was terminated after investigation. Resident #1 was cognitively impaired and required assistance with activities of daily living. The complaint was substantiated with minimal harm.

The facility failed to ensure Resident #1 was free from involuntary confinement when a nurse closed the resident's door in a manner that prevented the resident from leaving. The nurse was suspended and later terminated for failure to follow facility protocols. Resident #1 was cognitively impaired and at risk for elopement. No physical harm was found upon assessment.

Deficiencies were identified related to comprehensive care plans, nursing services, pharmacy services, infection control, emergency preparedness, and life safety code compliance. Several residents were found to be potentially affected by deficient practices, including medication errors and inadequate care planning.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents, inadequate nurse aide competency, inaccurate nurse staffing postings, medication management errors including missing narcotics and unadministered medications, failure to follow consultant pharmacist recommendations, improper infection control practices including inadequate cleaning and PPE use, improper COVID-19 testing and contact tracing, and poor food storage and sanitation practices.

The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure that all staff and residents were properly screened for COVID-19 signs and symptoms according to facility policy and CDC guidelines. Deficiencies involved 9 of 37 nursing employees and 4 of 5 residents reviewed.

The facility was found deficient in clarifying physician orders for enteral feeding, failure to have consultant pharmacist services for April 2021, improper medication labeling and storage, inadequate staffing and qualifications in food and nutrition services, failure to follow menus and provide correct meal portions, poor kitchen sanitation and food storage practices, improper infection control practices including PPE availability and hand hygiene, and failure to monitor antibiotic use according to the stewardship program.

The facility was found not in compliance with mandatory infection control and sanitation standards, specifically failing to ensure that a recently hired employee received a required physical examination or nursing assessment within the mandated timeframe.

The facility was found noncompliant with emergency preparedness requirements due to insufficient emergency food supplies not matching the emergency menu, and noncompliance with life safety code due to unsealed vertical openings in the laundry area ceiling allowing passage of fire, smoke, and fumes between floors.