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COMPLETE CARE AT BAYSHORE LLC Inspection Report, Violations & Safety Grade (HOLMDEL, New Jersey)

715 NORTH BEERS STREET, HOLMDEL, New Jersey 07733

Phone: 7327399000

CMS Overall:2/5

Overview & Bed Count

Certified Beds
232
Avg Residents/Day
140.9
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Monmouth
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall2/5
Health1/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityNew Jersey AvgDifference
RN Hours per Resident per Day0.380.70-0.32
Total Nurse Hours per Resident per Day3.923.90+0.02
CMS Staffing Rating2/53.2/5-
Nursing Staff Turnover36.8%39.3%-

Health Citation History

39 health citations on record

DateCategoryDescriptionSeverity
2026-05-08Nutrition and Dietary DeficienciesProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.F – Moderate Harm Potential
2026-05-08Nutrition and Dietary DeficienciesEnsure 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.F – Moderate Harm Potential
2026-05-08Nutrition and Dietary DeficienciesEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.F – Moderate Harm Potential
2026-05-08Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2026-05-08Administration DeficienciesHave a plan that describes the process for conducting QAPI and QAA activities.F – Moderate Harm Potential
2026-05-08Resident Rights DeficienciesReasonably accommodate the needs and preferences of each resident.E – Moderate Harm Potential
2026-05-08Resident Rights DeficienciesHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.E – Moderate Harm Potential
2026-05-08Freedom from Abuse, Neglect, and Exploitation DeficienciesPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.E – Moderate Harm Potential
2026-05-08Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.E – Moderate Harm Potential
2026-05-08Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.E – Moderate Harm Potential
2026-05-08Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2026-05-08Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.E – Moderate Harm Potential
2026-05-08Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E – Moderate Harm Potential
2026-05-08Pharmacy Service DeficienciesEnsure 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.E – Moderate Harm Potential
2026-05-08Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.E – Moderate Harm Potential
2026-05-08Freedom from Abuse, Neglect, and Exploitation DeficienciesDevelop and implement policies and procedures to prevent abuse, neglect, and theft.D – Moderate Harm Potential
2026-05-08Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.D – Moderate Harm Potential
2026-05-08Environmental DeficienciesMake sure that a working call system is available in each resident's bathroom and bathing area.D – Moderate Harm Potential
2026-04-16Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2025-12-29Administration DeficienciesConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.D – Moderate Harm Potential
2024-10-30Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2024-10-30Resident Rights DeficienciesPrepare residents for a safe transfer or discharge from the nursing home.D – Moderate Harm Potential
2024-10-30Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2024-10-30Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2024-10-30Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential
2024-10-30Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2024-10-30Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2024-04-04Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.E – Moderate Harm Potential
2024-02-14Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2023-10-19Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E – Moderate Harm Potential
2023-10-19Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2023-10-19Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2023-10-19Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2023-10-19Quality of Life and Care DeficienciesProvide for the safe, appropriate administration of IV fluids for a resident when needed.D – Moderate Harm Potential
2023-10-19Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-10-19Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.D – Moderate Harm Potential
2023-10-19Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2023-10-19Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2023-10-19Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.B – Minimal Harm Potential

Fire Safety Citation History

11 fire safety citations on record

DateCategoryDescriptionSeverity
2026-05-08Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).E – Moderate Harm Potential
2026-05-08Egress DeficienciesInstall emergency lighting that can last at least 1 1/2 hours.E – Moderate Harm Potential
2026-05-08Smoke DeficienciesProperly provide smoke detection systems in areas open to corridors.E – Moderate Harm Potential
2026-05-08Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.E – Moderate Harm Potential
2026-05-08Smoke DeficienciesHave an enclosure around a vertical opening shaft.D – Moderate Harm Potential
2026-05-08Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.D – Moderate Harm Potential
2024-10-30Smoke DeficienciesHave an enclosure around a vertical opening shaft.F – Moderate Harm Potential
2024-10-30Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.F – Moderate Harm Potential
2023-10-19Smoke DeficienciesHave an enclosure around a vertical opening shaft.F – Moderate Harm Potential
2023-10-19Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.F – Moderate Harm Potential
2023-10-19Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.F – Moderate Harm Potential

Total Penalties & Fines

$22,205
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
DateTypeFine AmountPayment Denial
2026-09-02Fine$22,205-

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