Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Inglemoor, Llc during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses and severe cognitive impairment experienced episodes of sedation and lethargy, with medications being held and changes in treatment occurring. Nursing staff documented these changes but did not notify the physician or the resident's representatives as required by facility policy. The deficiency was confirmed through record review and interviews with the DON.
A resident with severe malnutrition and cognitive impairment was not monitored with weekly weights as ordered by the physician and required by facility policy. Despite clear orders and standards, nursing and dietary staff failed to document or complete weekly weights for four weeks after admission, resulting in noncompliance with professional standards of practice.
A resident with multiple complex diagnoses had several instances where medications were held, but nursing staff failed to document the reasons in the Progress Notes as required. Additionally, unit assignment records for certain dates and shifts were missing, and facility leadership confirmed the incompleteness of the medical records and lack of a relevant policy.
The facility failed to maintain proper kitchen sanitation, resulting in a repeat deficiency. Observations included a stove backsplash with thick grease, a stand-up oven with grease buildup, and a freezer with frost accumulation. The FSD admitted the conditions were unacceptable, and there was no log or schedule for cleaning tasks, contrary to the facility's policy.
The facility failed to clarify physician orders and sequence PRN medications according to pain severity for several residents, leading to medication administration issues. Additionally, during medication pass observations, the facility did not ensure the availability of prescribed medications, resulting in the use of non-equivalent substitutes.
A facility failed to ensure a physician reviewed and signed orders for a resident, resulting in a deficiency. The orders were overdue for 982 days, and the resident had multiple medical conditions, including diabetes and heart failure. The physician's progress notes lacked a medication review, and the LPN was unsure of the process for signing orders. The DON confirmed the oversight, and the facility's policy aimed to ensure quality physician-ordered services.
The facility failed to maintain complete and accurate medical records for several residents, with discrepancies and omissions noted in documentation related to residents' conditions and Facility Reported Events (FREs). For one resident, there was a discrepancy between the DON's and APN's notes regarding extremity limitations. Other residents' records lacked documentation of FREs, with no mention of events or investigations in progress notes, despite facility policy requiring such documentation.
A resident with severe cognitive impairment and requiring maximal assistance was found to have their call bell on the floor, out of reach, after morning care. The CNA confirmed the call bell should have been accessible, but it was not. The facility's policy mandates that call bells be within reach of residents.
A facility failed to accurately document and review a resident's advance directives, resulting in a discrepancy between the resident's EMR, which indicated DNR/DNI, and a POLST form indicating a desire for resuscitation/CPR and DNI. The resident, who was cognitively intact, had diagnoses including respiratory failure and heart failure. The oversight was acknowledged by the DON, highlighting a failure in communication and verification of the resident's wishes.
A resident sustained a cut to the left eyebrow when an overbed table hit them, and the facility failed to conduct a thorough investigation into the incident. The CNA involved reported the incident as accidental, but the investigation lacked individual witness statements and supportive documentation. The facility's administration could not provide comprehensive records, and the investigation did not meet the standards outlined in their policies.
A facility failed to accurately code the MDS for a resident, leading to a deficiency. The resident, with multiple medical conditions including Alzheimer's and a recent fracture, was not accurately represented in the MDS regarding their non-weight bearing status. The facility lacked a specific MDS policy, relying on the RAI manual, which contributed to the error.
A facility failed to update a care plan and clarify a physician's order for a resident with a fractured right 5th metatarsal, leading to discrepancies in weight-bearing status. Additionally, a fall investigation was incomplete as it lacked a statement from the Maintenance Staff who found the resident on the floor. The resident had multiple medical conditions, including Alzheimer's Disease and difficulty walking, with moderately impaired cognition.
The facility failed to obtain weights for a resident according to physician's orders and policy, resulting in unmonitored significant weight loss. Additionally, the facility did not monitor or document fluid intake for another resident with fluid restrictions, as required by physician's orders. These deficiencies were identified through observations, interviews, and record reviews.
A facility failed to properly manage nebulizer equipment for a resident, resulting in a deficiency in respiratory care. The nebulizer mask was found uncovered and not changed since 2/18/25, contrary to the facility's policy of weekly changes. Staff were unsure of the policy, and there was no physician's order for the weekly change or a care plan for respiratory care. The facility's policy did not address proper storage of nebulizer equipment.
A surveyor observed that medication and medical supply storage cabinets on the second floor were not locked, contrary to the facility's policy and standards of practice. The LPN confirmed the cabinets should be locked but was unable to secure them. The Consultant Pharmacist and facility administrators acknowledged the need for secure storage to prevent unauthorized access.
A resident with type 2 diabetes and intact cognition was not offered or documented for influenza and pneumococcal vaccines, despite facility policies requiring such actions. The electronic medical records lacked evidence of vaccine offers, consent forms, or education provided. Interviews with staff confirmed the absence of documentation, and the issue was communicated to the LNHA and DON without additional response.
A resident with intact cognition and medical conditions including diabetes and malnutrition was not offered a COVID-19 vaccine, nor was there documentation of vaccine education or consent in their records. Interviews with facility staff confirmed the lack of documentation and adherence to the facility's vaccination policy.
A nurse in an LTC facility involuntarily confined a resident by attaching a hospital gown to the doorknob and handrail, preventing the resident from leaving their room. The resident, who had moderate cognitive impairment and a history of elopement risk, was found asleep in their room when the door was opened. The nurse claimed the action was to prevent wandering, but it violated the facility's policy against involuntary seclusion.
Failure to Notify Physician and Resident Representatives of Change in Condition
Penalty
Summary
The facility failed to notify the physician and the resident's representatives of significant changes in a resident's condition and status. The resident in question had multiple diagnoses, including type 2 diabetes mellitus, unspecified psychosis, severe protein-calorie malnutrition, and dementia with agitation, and was noted to have severely impaired cognition. Documentation in the medical record showed that the resident experienced episodes of sedation, lethargy, and required assistance with feeding and medication administration. On several occasions, nursing staff documented that the resident was sedated, medications were held, and the resident's condition deviated from their baseline. Despite these changes, there was no documented evidence that the resident's representatives or the physician were notified of the resident's altered condition, including when the resident was sedated, medications were withheld, or when there were changes in medication orders. The facility's own policy required prompt notification of the resident, physician, and resident representative in the event of significant changes in condition or treatment, such as deterioration in health or the need to alter treatment due to adverse consequences. However, the medical record lacked documentation of such notifications during the periods when the resident's condition changed. Interviews with the Director of Nursing confirmed that the expectation was for nursing staff to notify the resident's representatives and physician of any significant change in condition, including lethargy or sedation outside the resident's norm, and to document this communication. The surveyors found no additional information or documentation to indicate that the required notifications had occurred, confirming the deficiency in following notification protocols as outlined in facility policy and regulatory requirements.
Failure to Monitor Weekly Weights for Malnourished Resident
Penalty
Summary
A resident with severe protein-calorie malnutrition, dementia with agitation, persistent mood disorders, and unspecified psychosis was admitted/readmitted to the facility from a geriatric psychiatric hospital. The resident was assessed as severely malnourished and underweight, with a physician's order for weekly weights for four weeks upon admission/readmission, a regular diet, and Ensure Plus twice daily as a supplement. The facility's policy and the Registered Dietitian's standard of practice also required weekly weight monitoring for newly admitted residents. However, a review of the electronic medical and treatment administration records revealed that weekly weights were not documented for the resident as required. Interviews with the DON and RD confirmed that the weekly weights were not completed according to the physician's order and facility policy. The DON acknowledged the omission, and the RD stated that she typically only monitored monthly weights, despite the requirement for weekly monitoring in this case. The facility's weight monitoring policy specified that newly admitted residents should have weights taken on admission and then weekly for four weeks, which was not followed for this resident.
Incomplete Medical Records and Missing Documentation for Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by professional standards. Review of the closed medical record revealed that the resident, who had multiple diagnoses including type 2 diabetes, psychosis, severe malnutrition, and dementia with agitation, had several medication orders documented in the electronic Medication Administration Record (eMAR). However, on multiple occasions when medications such as lorazepam, mirtazapine, trazodone, and Ativan were held, there was no corresponding documentation in the Progress Notes by nursing staff explaining the reasons for holding the medications. Specific dates and times were identified where the eMAR indicated medications were not administered, but the required explanatory notes were missing. Additionally, the facility was unable to provide complete unit assignment records for certain dates and shifts, which the Director of Nursing (DON) confirmed were considered part of the residents' medical records. The DON acknowledged that the medical records should be complete and was unable to provide a policy regarding medical records when requested. The incomplete documentation and missing records were confirmed during interviews with the DON and the President of Clinical Services.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation in the kitchen, leading to a repeat deficiency. During an inspection, the surveyor observed several unsanitary conditions, including a main stove backsplash covered with a heavy, dry, thick brown substance identified as grease, which was not effectively cleaned by the Food Service Director (FSD). Additionally, a stand-up oven had a dry, white substance splattered on its side, and its interior was coated with thick, grease-like substances, particularly around the fan. The FSD acknowledged that the oven should not be in such a condition. Furthermore, a large ice cream freezer was found with frost accumulation around its upper edge, which the FSD admitted should not be present. The facility's cleaning practices were scrutinized, revealing that stoves and ovens were cleaned every two weeks and as needed, but there was no log or schedule indicating when the equipment was last cleaned. The FSD mentioned that cleaning tasks were written on the dietary staff's daily assignments, but the schedule provided did not specify the last cleaning dates for the stove, oven, and freezer. The facility's General Kitchen Cleaning Policy, revised in February 2024, mandates that cleaning and sanitation tasks be recorded, which was not adhered to, contributing to the deficiency.
Medication Administration and Order Clarification Deficiencies
Penalty
Summary
The facility failed to clarify physician orders for two residents, leading to medication administration issues. For one resident, the physician's orders for Ibuprofen and Tylenol did not specify the total milligrams for the prescribed doses, which was not clarified until the surveyor brought it to the attention of the Director of Nursing (DON). Another resident had a similar issue with unclear orders for Pantoprazole, Sertraline, and PRN pain medications, which were not clarified until after the surveyor's intervention. Additionally, the resident's enteral feeding order lacked a specified total volume, which was not addressed until the resident returned from the hospital. The facility also failed to sequence PRN medications according to pain severity for three residents. One resident receiving hospice care had PRN orders for morphine and acetaminophen that did not specify the pain level for administration. The Licensed Practical Nurse (LPN) acknowledged the lack of clarity in the orders and intended to discuss it with the DON. Another resident had similar issues with PRN orders for Tylenol and Morphine Sulfate, which were not sequenced according to pain severity, leading to potential confusion in pain management. During medication pass observations, the facility failed to ensure medications were available for two residents. One resident was supposed to receive ACT mouthwash, but it was not available, and a different mouthwash was used instead. Another resident was to receive Lactobacillus Rhamnosus, but a different probiotic was administered due to a lack of availability. These discrepancies were noted by the surveyor, and the facility's Consultant Pharmacist confirmed that the substituted products were not equivalent to the prescribed medications.
Physician Order Review Deficiency
Penalty
Summary
The facility failed to ensure that a physician reviewed and signed the orders for a resident, leading to a deficiency in physician services. The orders, which included medications and treatments, were overdue for review by 982 days. This issue was identified for one resident who had multiple medical diagnoses, including type 2 diabetes mellitus, gastrostomy status, and chronic systolic heart failure. The resident's cognition was severely impaired, as indicated by a BIMS score of 1 out of 15. The surveyor observed that the physician's progress notes did not reflect a review of all medications for the resident. Additionally, the Licensed Practical Nurse was unsure of the facility's process for signing monthly and telephone orders. The Director of Nursing confirmed that the physician had not signed the monthly orders for 982 days, and the notes did not include a medication review. The facility's Physician Services Policy was reviewed, which aimed to provide a reliable process for physician-ordered services according to professional standards of quality.
Deficient Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents, as evidenced by discrepancies and omissions in documentation. For Resident #6, there was a noted discrepancy between the Director of Nursing's (DON) progress notes and those of the Advanced Practice Nurse (APN) regarding the resident's extremity limitations. The DON's notes indicated limitations in the left upper and right lower extremities, which were not reflected in the APN's notes. This inconsistency was acknowledged by the DON, who stated that the limitations had been present since admission. For Resident #40, the medical record lacked documentation related to a Facility Reported Event (FRE) on 11/16/24. Although a nurse's assessment note mentioned a room transfer due to medical necessity, there was no further documentation or investigation related to the FRE in the progress notes from any department. Similarly, for Resident #24, there was no mention of the FRE or any related investigation in the progress notes, despite a psychiatric consult indicating an incident corresponding to the FRE. Resident #36's medical record also lacked documentation of an FRE on 12/23/24, with no mention of the event or investigation in the progress notes. The record did include assessments and a room transfer related to the timeframe, but no specific details about the FRE. For Resident #3, the medical record did not contain any mention of the FRE or related investigation, and the facility could not provide additional progress notes. The facility's policy required staff to document incidents in the electronic medical record, but the investigations were kept in separate files, not integrated into the medical records.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call bell was within reach, which is a requirement for residents who need assistance and can use a call bell. This deficiency was observed for one resident who had severe cognitive impairment and required maximal assistance with activities of daily living. During a survey, the call bell was found on the floor, out of the resident's reach, after morning care was provided by a CNA. The resident indicated that they would call for help by shouting, as the call bell was not accessible. The surveyor confirmed the call bell's position on the floor during multiple visits to the resident's room. The CNA acknowledged the call bell should have been within the resident's reach but did not know how it ended up on the floor. The facility's policy requires call bells to be positioned conveniently for use and within reach of residents. The deficiency was reported to the LNHA and other facility leaders, who acknowledged the expectation for call bells to be accessible to residents.
Failure to Accurately Document and Review Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation and review of a resident's advance directives, specifically for a resident with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and heart failure. The resident was cognitively intact with a BIMS score of 13 out of 15. The resident's electronic medical record (EMR) indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, while a paper chart contained a POLST form signed by the resident and a physician, indicating a desire for resuscitation/CPR and DNI. This discrepancy was not identified or corrected by the facility staff. The Director of Nursing (DON) and social services staff were responsible for determining and documenting the resident's code status upon admission. However, there was a lack of communication and verification regarding the resident's wishes, as the POLST form completed by the resident was not reflected in the EMR. The DON acknowledged the oversight and the need for clarification of the resident's code status. The facility's policy required that the plan of care be consistent with the resident's documented treatment preferences, which was not adhered to in this case.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who sustained a cut to the left eyebrow. The incident occurred when a Certified Nurse Aide (CNA) attempted to adjust an overbed table that was stuck, resulting in the table hitting the resident's forehead. The resident, who was on blood thinner medication, was assessed for injury and transferred to a hospital emergency room for further evaluation. The facility's initial investigation concluded that the incident was accidental and not intentional, based on interviews with the resident and staff involved. However, the investigation was incomplete as it lacked individual witness statements and additional supportive documentation. The facility's administration, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), were unable to provide comprehensive documentation of the investigation, citing difficulties in locating records from the previous administration. The police were involved and took statements from the resident and the CNA, but the facility did not have a complete police report at the time of the survey. The facility's policies required obtaining written documentation from witnesses and direct care staff involved in incidents, but these were not provided. The surveyor noted that the facility's investigation did not meet the standards outlined in their policies for handling allegations of abuse, neglect, or mistreatment. The lack of a comprehensive investigation and documentation was identified as a deficiency by the survey team.
Inaccurate MDS Coding for Resident
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, which is a critical assessment tool used to manage care in accordance with federal guidelines. The deficiency was identified during a survey when it was observed that the MDS did not accurately reflect the resident's status and limitations. Specifically, the MDS with an assessment reference date of January 16, 2025, indicated that the resident had a functional limitation in range of motion and impairment on the upper extremity, but did not accurately capture the resident's non-weight bearing status on the right lower extremity following a fracture. The resident, who was admitted with multiple medical diagnoses including Alzheimer's Disease, dysarthria, osteoarthritis, and contracture of the left hand, had a fall incident resulting in a fracture on December 2, 2024. This incident required the resident to be non-weight bearing on the right lower extremity. Despite these conditions, the MDS did not accurately reflect the resident's current status, as confirmed by the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The facility lacked a specific policy for MDS, relying instead on the Resident Assessment Instrument (RAI) manual, which contributed to the inaccurate coding.
Failure to Update Care Plan and Complete Fall Investigation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, there was a failure to clarify a physician's order and revise the care plan (CP) for a resident with a fractured right 5th metatarsal. The physician's order dated 12/11/24 indicated non-weight bearing (NWB) status for the resident's right lower extremity, but a progress note created by the Director of Nursing (DON) on 3/1/25 reflected a change to weight bearing as tolerated (WBAT) with a boot. The DON acknowledged that the CP should have been updated to reflect the WBAT status since 2/12/25, and the order for NWB should have been clarified. Additionally, the facility did not complete a thorough investigation of a fall incident involving the same resident. The fall occurred on 12/2/24, and the investigation report did not include a statement from the Maintenance Staff (MS) who found the resident on the floor. The DON confirmed that it was her responsibility to ensure that the MS's statement was obtained, but this was not done. The facility's policy requires that written documentation of the event be obtained from witnesses and submitted to the DON and/or Administrator. The resident involved had multiple medical diagnoses, including Alzheimer's Disease, dysarthria following a stroke, osteoarthritis, and difficulty walking. The resident's cognition was moderately impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. The failure to update the CP and clarify the physician's order, along with the incomplete fall investigation, demonstrate deficiencies in the facility's adherence to professional standards of practice and policy compliance.
Failure to Monitor Resident Weights and Fluid Restrictions
Penalty
Summary
The facility failed to obtain weights for a resident according to the physician's orders and facility policy. Resident #13, who had diagnoses including respiratory failure, chronic obstructive pulmonary disease, and heart failure, experienced significant weight loss. The facility did not obtain weights upon the resident's re-admission on two occasions, and monthly weights were not completed by the expected date. The facility's policy required weights to be taken upon admission and weekly for four weeks, but this was not adhered to, leading to a lack of monitoring of the resident's weight changes. Additionally, the facility failed to monitor and document fluid intake for Resident #28, who had a physician's order for fluid restrictions due to End Stage Renal Disease. The resident's fluid restriction was not documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and the nursing staff was not aware of the fluid restriction. The facility's policy required fluid restrictions to be documented and monitored, but this was not done, resulting in a lack of adherence to the physician's orders. The deficiencies were identified through observations, interviews, and record reviews conducted by the surveyor. The Director of Nursing (DON) and other facility staff acknowledged the issues and indicated that in-service education was being provided to address the deficiencies. However, the report focuses on the failure to follow established protocols for weight monitoring and fluid restriction documentation, which led to the identified deficiencies.
Deficiency in Respiratory Care Due to Improper Nebulizer Equipment Management
Penalty
Summary
The facility failed to ensure appropriate storage and timely replacement of nebulizer equipment for a resident, leading to a deficiency in respiratory care. During an observation, a nebulizer mask was found resting uncovered on a nightstand, with a date indicating it had not been changed since 2/18/25, contrary to the facility's policy of weekly changes. Licensed Practical Nurse (LPN) #1 was unsure of the facility's policy regarding the changing of nebulizer tubing and mask equipment. The Minimum Data Set (MDS) Coordinator confirmed that the equipment should have been changed weekly, and the Director of Nursing (DON) acknowledged that the mask should have been stored in a plastic bag when not in use. The resident involved was admitted with diagnoses including type 2 diabetes mellitus and dysphagia, and had a physician's order for Budesonide Inhalation Suspension for asthma. However, there was no physician's order for the weekly change of nebulizer tubing, nor was there a care plan related to the resident's respiratory care. The DON confirmed that the facility's protocol was not followed, as there was no order for the weekly change of nebulizer tubing, and the equipment was not stored properly. The facility's Oxygen Administration Policy did not address the storage of nebulizer equipment, contributing to the oversight.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications and medical supplies safely and according to standards of practice. This deficiency was identified in one of the two medication storage areas observed on the second floor. During an observation, a surveyor noted that a medication storage cabinet containing various in-house stock medications was not locked. Additionally, two other storage cabinets containing various medical supplies were also found unlocked and did not have locks affixed. The Licensed Practical Nurse (LPN) present confirmed that the cabinets should always be locked and attempted to locate a key to secure them but was unsuccessful. The surveyor further confirmed with the facility's Consultant Pharmacist (CP) that all medications and medical supplies should be stored securely to prevent unauthorized access. The Licensed Nursing Home Administrator (LNHA) and the Regional Vice President of Clinical Services (RVPoCS) were informed of the unsecured medication storage cabinets. They acknowledged that all medications and medical supplies should be kept secured from unauthorized access. The facility's Medication Storage Policy, last reviewed in October 2024, also reflected that all drugs and biologicals should be stored in locked compartments.
Failure to Document and Offer Vaccines
Penalty
Summary
The facility failed to offer and document the administration or refusal of pneumococcal and influenza vaccines for a resident, leading to a deficiency. The resident, who had intact cognition and was diagnosed with type 2 diabetes mellitus with hyperglycemia and moderate protein-calorie malnutrition, did not have documented evidence of being offered the influenza vaccine, although the pneumococcal vaccine was up to date. The electronic medical records lacked documentation of the resident's immunization history, consent forms, or education provided regarding the vaccines. Interviews with the Infection Preventionist Nurse (IPN) and Licensed Practical Nurse (LPN) revealed that the influenza vaccine was supposed to be offered to all residents by the end of September and March, and the pneumococcal vaccine was to be checked for prior administration. However, there was no documentation in the resident's records to confirm that these vaccines were offered or declined, nor was there evidence of education provided. The LPN confirmed the absence of signed consent forms and stated that it was the responsibility of the admitting nurse and IPN to ensure these were completed. The facility's policies for influenza and pneumococcal vaccines required offering the vaccines to residents, documenting education provided, and recording any refusals. Despite these policies, the surveyor found no evidence that the resident was offered the vaccines or that any education was documented. The surveyor's findings were communicated to the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), but no additional information or response was provided by them during the exit conference.
Failure to Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to offer a COVID-19 immunization to a resident, identified as Resident #55, which was discovered during a survey. The resident had been admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia and moderate protein-calorie malnutrition. Despite having an intact cognition as indicated by a BIMS score of 15 out of 15, there was no documented evidence in the resident's medical records that the COVID-19 vaccine was offered, declined, or that education about the vaccine was provided. The electronic record under the immunization tab lacked any information about the resident's COVID-19 immunization status, and there were no consent forms on file. Interviews with the Infection Preventionist Nurse (IPN) and a Licensed Practical Nurse (LPN) confirmed the absence of documentation and consent forms. The IPN stated that vaccines are typically offered when new vaccines are available and upon new admissions, and that all documentation should be recorded in the electronic medical records. The LPN indicated that it was the responsibility of the admitting nurse and the IPN to ensure consent forms are signed and offered. The facility's COVID-19 Vaccination Policy, reviewed by the Licensed Nursing Home Administrator (LNHA), emphasized the importance of educating and offering the vaccine to residents and staff, yet this was not adhered to in the case of Resident #55.
Resident Involuntarily Confined by Nurse
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary confinement. On a night shift, a nurse attached a hospital gown to the doorknob of a resident's room and looped it to the handrail in the hallway, effectively preventing the resident from leaving the room. This action was taken after the resident, who was in a wheelchair, was brought back to their room from another resident's room. The incident was reported by another resident who noticed the door was closed in a way that would prevent the resident from leaving. The resident involved had a history of osteoarthritis, psychosis, bipolar disorder, abnormalities of gait and mobility, gastro-esophageal reflux disease, and atherosclerotic heart disease. The resident's cognitive function was moderately impaired, as indicated by a Brief Interview for Mental Status score of 12. The resident required assistance with activities of daily living but was independent in eating and mobility while in bed and could propel themselves in a wheelchair. The resident's care plan noted a risk for elopement, with interventions to monitor and divert the resident's attention. The nurse involved in the incident stated that she closed the door in this manner to keep the resident safe from wandering during the night. However, when another resident informed her that the door should not be closed in that way, she opened it. The facility's policy on abuse, neglect, and exploitation prohibits involuntary seclusion, which includes confining a resident to their room against their will. The nurse was subsequently terminated for failing to follow facility protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,626 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Englewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Family Of Caring At Teaneck Llc | 1.5 mi | ★★★★★ | 17 | 0 |
| Careone At Teaneck | 1.8 mi | ★★★★★ | 0 | 0 |
| Actors Fund Home | 2 mi | ★★★★★ | 0 | 0 |
| Fort Tryon Center For Rehabilitation And Nursing | 2.8 mi | ★★★★★ | 5 | 0 |
| Independence Care Center For Nursing And Rehabilit | 3.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Complete Care At Inglemoor, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.