Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT SHREWSBURY LLC
SHREWSBURY, NJ · 140 certified beds · Last Life Safety survey September 25, 2025
CMS Certification Number 315136 · first certified March 1972
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed March 16, 2023 (change of ownership)from HACKENSACK MERIDIAN AMBULATORY CARE, INC.
Position within NJ
13 citations — more than 38% 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 4 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was September 2025. 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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Physical environment (health survey)
3 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 13 Life Safety citations above. The Physical Environment Index
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 | 13 |
| Median facility in NJ | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 10, 2022 | 1 |
| May 30, 2024 | 8 |
| September 25, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-09-25 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2022-03-10 |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | 1 | 2024-05-30 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-05-30 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-05-30 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-09-25 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2024-05-30 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-05-30 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 25, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (October 25, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 25, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 25, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 25, 2025) |
May 30, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 19, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 19, 2024) |
March 10, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 15, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.