Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Complete Care at Bayshore LLC
HOLMDEL, NJ · 232 certified beds · Last Life Safety survey October 30, 2024
CMS Certification Number 315252 · first certified January 1988
Ownership
Operated by COMPLETE CARE · For profit - Corporation
- Ownership changed March 16, 2023 (change of ownership)from HACKENSACK MERIDIAN AMBULATORY CARE, INC.
Position within NJ
14 citations — more than 44% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (February 2026 to July 2026). Most NJ facilities have been surveyed by December 2026. This facility’s last Life Safety survey was October 2024. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 3, 2022 | 9 |
| October 19, 2023 | 3 |
| October 30, 2024 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | 3 | 2024-10-30 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2023-10-19 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2024-10-30 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2022-08-03 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2022-08-03 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2022-08-03 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2022-08-03 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2022-08-03 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 30, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (November 12, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 12, 2024) |
October 19, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (November 1, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 1, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 1, 2023) |
August 3, 2022 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 4, 2022) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (September 13, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 13, 2022) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Waiver has been granted (October 12, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 12, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 13, 2022) |
| K-0364 | Install properly constructed windows in hallway walls or doors. | Deficient, Provider has date of correction (September 13, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 13, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 12, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.