Complete Care at Bayshore LLC
715 NORTH BEERS STREET, HOLMDEL, NJ 07733
Below the repealed 0.55 hr RN benchmark — average inspection record.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.49 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
37
Outstanding
0
Actual harm or worse (G–L)
1
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★★★ (5/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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64/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
1 actual harm issue found among 37 total deficiencies. 37 corrected.
Most recent inspection (December 29, 2025)
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.
Administration Deficiencies — Deficient, Provider has date of correction, corrected February 13, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2024
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2024
Inspection cycle 2 (October 19, 2023)
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 3, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 1, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 17, 2023
Prepare residents for a safe transfer or discharge from the nursing home.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2024
Inspection cycle 3 (August 3, 2022)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 3, 2022
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
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.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 12, 2024
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Ensure the activities program is directed by a qualified professional.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 21, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 13, 2022
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