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Complete Care at Bayshore LLC

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Complete Care at Bayshore LLC is a for profit - corporation facility in HOLMDEL, NJ with 232 certified beds and a 4-star overall CMS rating. The facility has 37 deficiency records on file.

715 NORTH BEERS STREET, HOLMDEL, NJ 07733

Phone: 7327399000

Overall Rating

4/5

Health Inspection

3/5

Staffing

2/5

Quality Measures

5/5

Long-Stay Quality

5/5

Facility Information

Provider Number
315252
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
Beds
232
Residents
141
In Hospital
No
County
Monmouth
Last Inspection
Oct 30, 2024

Staffing Data

RN Hours
0.49 (nat'l avg: 0.68)
LPN Hours
1.07
CNA Hours
2.11
Total Nursing Hours
3.67 (nat'l avg: 3.89)
PT Hours
0.08
Nursing Turnover
40.0%
RN Turnover
35.3%

What the CMS Record Reveals About Complete Care at Bayshore LLC

Complete Care at Bayshore LLC operates 232 certified beds in HOLMDEL, NJ with approximately 141 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 37 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.67 total nursing hours per resident day (national average 3.89), with RN coverage at 0.49 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Complete Care at Bayshore LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 40.0%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (37 most recent)

D — Isolated - Minimal harm Dec 29, 2025 Tag: 0838

Conduct 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.

Category: Administration Deficiencies

D — Isolated - Minimal harm Oct 30, 2024 Tag: 0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 11, 2024

D — Isolated - Minimal harm Oct 30, 2024 Tag: 0624

Prepare residents for a safe transfer or discharge from the nursing home.

Category: Resident Rights Deficiencies

Corrected: Nov 11, 2024

F — Widespread - Minimal harm Oct 30, 2024 Tag: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 12, 2024

D — Isolated - Minimal harm Oct 30, 2024 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Nov 11, 2024

D — Isolated - Minimal harm Oct 30, 2024 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Nov 11, 2024

D — Isolated - Minimal harm Oct 30, 2024 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 11, 2024

D — Isolated - Minimal harm Oct 30, 2024 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 11, 2024

E — Pattern - Minimal harm Apr 4, 2024 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: May 1, 2024

D — Isolated - Minimal harm Feb 14, 2024 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Mar 12, 2024

B — Pattern - No harm Oct 19, 2023 Tag: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 17, 2023

E — Pattern - Minimal harm Oct 19, 2023 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Nov 17, 2023

D — Isolated - Minimal harm Oct 19, 2023 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 17, 2023

E — Pattern - Minimal harm Oct 19, 2023 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Nov 17, 2023

D — Isolated - Minimal harm Oct 19, 2023 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Nov 17, 2023

D — Isolated - Minimal harm Oct 19, 2023 Tag: 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Category: Pharmacy Service Deficiencies

Corrected: Nov 17, 2023

D — Isolated - Minimal harm Oct 19, 2023 Tag: 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 17, 2023

D — Isolated - Minimal harm Oct 19, 2023 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 17, 2023

D — Isolated - Minimal harm Oct 19, 2023 Tag: 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 3, 2023

D — Isolated - Minimal harm Oct 19, 2023 Tag: 0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 17, 2023

F — Widespread - Minimal harm Aug 3, 2022 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Oct 3, 2022

F — Widespread - Minimal harm Aug 3, 2022 Tag: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Category: Nutrition and Dietary Deficiencies

Corrected: Sep 13, 2022

F — Widespread - Minimal harm Aug 3, 2022 Tag: 0809

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Category: Nutrition and Dietary Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Category: Nutrition and Dietary Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0758

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.

Category: Pharmacy Service Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0693

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0692

Provide enough food/fluids to maintain a resident's health.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 13, 2022

G — Isolated - Actual harm Aug 3, 2022 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 13, 2022

F — Widespread - Minimal harm Aug 3, 2022 Tag: 0680

Ensure the activities program is directed by a qualified professional.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 21, 2022

F — Widespread - Minimal harm Aug 3, 2022 Tag: 0679

Provide activities to meet all resident's needs.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Sep 13, 2022

C — Widespread - No harm Aug 3, 2022 Tag: 0625

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Category: Resident Rights Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Sep 13, 2022

D — Isolated - Minimal harm Aug 3, 2022 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Sep 13, 2022

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 3.9% Yes
Percentage of long-stay residents who lose too much weight Long Stay 1.7% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 1.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.5% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 10.1% No
Percentage of long-stay residents who were physically restrained Long Stay 0.2% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 0.9% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 100.0% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 99.7% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 1.3% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 5.8% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 23.6% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 100.0% No
Percentage of long-stay residents with pressure ulcers Long Stay 5.0% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 13.6% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 10.7% Yes

Penalty History

No penalties on record.

Frequently Asked Questions

What is the overall CMS rating for Complete Care at Bayshore LLC?
Complete Care at Bayshore LLC has an overall CMS rating of 4 out of 5 stars. This rating combines health inspection results (3★), staffing levels (2★), and quality measures (5★).
What are the staffing levels at Complete Care at Bayshore LLC?
Complete Care at Bayshore LLC reports 3.67 total nursing hours per resident day (national average: 3.89). RN hours are 0.49 per resident day (national average: 0.68). Nursing staff turnover is 40.0%.
How many beds does Complete Care at Bayshore LLC have?
Complete Care at Bayshore LLC has 232 certified beds with approximately 141 residents. The facility is located at 715 NORTH BEERS STREET, HOLMDEL, NJ 07733.
Does Complete Care at Bayshore LLC have any deficiencies on record?
Yes, Complete Care at Bayshore LLC has 37 deficiencies on record from recent inspections. Of these, 1 are classified as causing actual harm or jeopardy.
Has Complete Care at Bayshore LLC received any fines or penalties?
No, Complete Care at Bayshore LLC has no fines or penalties on record.
Who owns Complete Care at Bayshore LLC?
Complete Care at Bayshore LLC is classified as "For profit - Corporation" ownership. The facility type is "Medicare and Medicaid".
When was Complete Care at Bayshore LLC last inspected?
The most recent health inspection for Complete Care at Bayshore LLC was on Oct 30, 2024. The facility received a health inspection rating of 3 out of 5 stars.
What quality measures are tracked for Complete Care at Bayshore LLC?
Complete Care at Bayshore LLC is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial