Complete Care at Inglemoor, LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Inglemoor, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 13, 2025

  REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/7/25 at 9:35 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the initial kitchen tour: 1. The surveyor observed the main stove-back splash with heavy, dry, thick brown substances. The FSD stated, It's grease .we clean it every two weeks sometimes a bit more with degreaser. The surveyor observed the FSD attempt to wipe off the thick brown substance on the back splash with his fingers, but the brown substance only smeared further. 2. […]

• No harm, potential for more than minimal, widespreadF880Jan 26, 2023

  Based on observation, interview, record review, and review of the facility provided documentation, it was determined that the facility failed to: a) establish, assess, and maintain record measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems, this deficient practice had the potential to affect all 54 residents; b) properly doffed (remove) and discard the PPE (personal protective equipment) for one of three staff observed; c) perform handwashing appropriately for one (Certified Nursing Aide) of six staff observed for hand hygiene; d) disinfect and sanitize the equipment used for checking blood pressure for one of two nurses during medication administration), and e) adhere to accepted standards of infection control practices for the proper… […]

• No harm, potential for more than minimal, widespreadF801May 5, 2021

  Based on interview and review of facility documents, it was determined that the facility failed to a.) employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, b). employ a full-time dietitian, or c.) employ a qualified director of food and nutrition services. This deficient practice was evidence by the following: On [DATE] at 9:38 AM, the surveyor interviewed the Dining Services Director (DSD) in the presence of another surveyor. The DSD stated that he was Serve Safe Certified. On [DATE] at 10:29 AM, the surveyor interviewed the Registered Dietitian (RD) in the presence of another surveyor. She stated that she worked two -eight-hour days a week, usually Tuesdays and Thursdays. […]

• No harm, potential for more than minimal, widespreadF812May 5, 2021

  Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous and dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during two kitchen tours and was evidenced by the following: On [DATE] at 9:38 AM, the surveyor conducted an initial tour with the Dining Services Director (DSD) in the presence of another surveyor and observed the following: There was a small black plastic garbage bin without a lid, uncovered and overflowing with trash at the handwashing sink. […]

• No harm, potential for more than minimal, patternF658Mar 13, 2025

  Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to; a.) clarify the physician orders for 2 of 18 residents, (Residents #6 and #159), b.) ensure as needed (PRN) medications were sequenced according to pain severity for 3 of 18 residents (Residents #6, #48, and #159), and c.) ensure that medications were available for 2 of 3 residents reviewed during medication pass observation, (Residents #15 and #21), according to the standard of clinical practice and facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. […]