Holmdel, NJ

Complete Care at Bayshore LLC

4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

715 North Beers Street, Holmdel, NJ

(732) 739-9000

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

232

Certified beds

Average residents

141

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1988-01-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

85 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.49

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

1.07

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

2.11

Nurse aide staffing · state 2.23 · national 2.35

Total nurse hours

3.67

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

3.38

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.42

CMS adjusted RN staffing hours

Adjusted total hours

3.17

CMS adjusted total nurse staffing hours

Case-mix index

1.58

Higher values indicate more complex resident acuity

RN turnover

35%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

40%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,544

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.34

Composite VBP score used to determine payment impact.

Payment multiplier

0.9831

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.91

Baseline 23.63% · Performance 19.40% · Measure score 5.91 · Achievement 4.38 · Improvement 5.91

Healthcare-associated infections

0

Baseline 7.92% · Performance 8.54% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.43

Baseline 53.09% · Performance 49.66% · Measure score 3.43 · Achievement 3.43 · Improvement 0.71

Adjusted total nurse staffing

0

Baseline 3.85 hours · Performance 2.97 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.69%
10.72%
1 pts better
No Different than the National Rate · Eligible stays 290 · Observed rate 11.03% · Lower 95% interval 7.31%
Discharge to community 54.02%
50.57%
3.5 pts better
No Different than the National Rate · Eligible stays 287 · Observed rate 44.25% · Lower 95% interval 47.66%
Medicare spending per beneficiary 1.21
1.02
0.2 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 201 · Denominator 201
Falls with major injury 1%
0.77%
0.2 pts worse
Numerator 2 · Denominator 201
Discharge self-care score 66.67%
53.69%
13 pts better
Numerator 80 · Denominator 120
Discharge mobility score 58.33%
50.94%
7.4 pts better
Numerator 70 · Denominator 120
Pressure ulcers or injuries, new or worsened 1.49%
2.29%
0.8 pts better
Numerator 3 · Denominator 201 · Adjusted rate 1.21%
Healthcare-associated infections requiring hospitalization 8.54%
7.12%
1.4 pts worse
No Different than the National Rate · Eligible stays 179 · Observed rate 12.29% · Lower 95% interval 5.59%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 166
Staff flu vaccination coverage 98.14%
42%
56.1 pts better
Numerator 158 · Denominator 161
Discharge function score 80.83%
56.45%
24.4 pts better
Numerator 97 · Denominator 120
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 75 · Denominator 75
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 65 · Denominator 65
Resident COVID-19 vaccinations up to date 17.58%
25.2%
7.6 pts worse
Numerator 16 · Denominator 91

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.4
2.1
0.3 pts worse
1.9
0.5 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.8 · Expected 3.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.7
1.1
0.4 pts better
1.8
1.1 pts better
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
93.0%
7 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
97.2%
2.8 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury 0.9%
2.4%
1.5 pts better
3.3%
2.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 1.0% · Q4 0.9% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 10.1%
11.4%
1.3 pts better
11.4%
1.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.3% · Q3 7.4% · Q4 16.2% · 4Q avg 10.1%
Percentage of long-stay residents who lose too much weight 1.7%
4.6%
2.9 pts better
5.4%
3.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.0% · Q3 0.0% · Q4 0.9% · 4Q avg 1.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 23.6%
19.0%
4.6 pts worse
19.6%
4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 26.9% · Q3 21.6% · Q4 20.0% · 4Q avg 23.6%
Percentage of long-stay residents who received an antipsychotic medication 10.7%
13.5%
2.8 pts better
16.7%
6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 7.4% · Q3 12.9% · Q4 12.9% · 4Q avg 10.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.2%
0.1%
0.1 pts worse
0.1%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2%
Percentage of long-stay residents whose ability to walk independently worsened 5.8%
9.8%
4 pts better
16.3%
10.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.7% · Q3 5.6% · Q4 7.0% · 4Q avg 5.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 3.9%
9.7%
5.8 pts better
14.9%
11 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 8.8% · Q3 2.3% · Q4 3.3% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.0%
0.7%
0.3 pts worse
1.0%
About the same
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 2.2% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.5%
0.8%
0.3 pts better
1.7%
1.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 13.6%
15.9%
2.3 pts better
19.8%
6.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 15.1% · Q3 12.3% · Q4 19.1% · 4Q avg 13.6%
Percentage of long-stay residents with pressure ulcers 5.0%
6.0%
1 pts better
5.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.9% · Q3 7.1% · Q4 5.9% · 4Q avg 5.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.7%
78.7%
21 pts better
81.7%
18 pts better
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.7%
Percentage of short-stay residents who had an outpatient emergency department visit 7.3%
8.2%
0.9 pts better
12.0%
4.7 pts better
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.1% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.3%
1.2%
0.1 pts worse
1.6%
0.3 pts better
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 100.0%
80.1%
19.9 pts better
79.7%
20.3 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.8%
25.4%
2.6 pts better
23.9%
1.1 pts better
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 25.2% · Expected 26.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-30 · Fire 2024-10-30

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-10-19 · Fire 2023-10-19

13 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-08-03 · Fire 2022-08-03

18 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-30

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-11-12

F · Potential for more than minimal harm 2024-10-30

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-11-12

F · Potential for more than minimal harm 2023-10-19

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2023-11-01

F · Potential for more than minimal harm 2023-10-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-11-01

F · Potential for more than minimal harm 2023-10-19

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-11-01

F · Potential for more than minimal harm 2022-08-03

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-10-04

F · Potential for more than minimal harm 2022-08-03

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2022-09-13

F · Potential for more than minimal harm 2022-08-03

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-10-12

F · Potential for more than minimal harm 2022-08-03

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-10-12

F · Potential for more than minimal harm 2022-08-03

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-09-13

F · Potential for more than minimal harm 2022-08-03

K364 · Smoke Deficiencies

Fire Safety

Install properly constructed windows in hallway walls or doors.

Corrected 2022-09-13

F · Potential for more than minimal harm 2022-08-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-10-12

E · Potential for more than minimal harm 2022-08-03

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-09-13

E · Potential for more than minimal harm 2022-08-03

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-09-13

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-29

F838 · Administration Deficiencies

Health

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.

Corrected 2026-02-13

F · Potential for more than minimal harm 2024-10-30

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-11-12

D · Potential for more than minimal harm 2024-10-30

F624 · Resident Rights Deficiencies

Health

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

Corrected 2024-11-11

D · Potential for more than minimal harm 2024-10-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-11-11

D · Potential for more than minimal harm 2024-10-30

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-11-11

D · Potential for more than minimal harm 2024-10-30

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-11-11

D · Potential for more than minimal harm 2024-10-30

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2024-11-11

D · Potential for more than minimal harm 2024-10-30

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-11-11

E · Potential for more than minimal harm 2024-04-04

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-05-01

D · Potential for more than minimal harm 2024-02-14

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2024-03-12

E · Potential for more than minimal harm 2023-10-19

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-19

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-19

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-19

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-03

D · Potential for more than minimal harm 2023-10-19

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-19

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-19

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-19

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-11-17

B · Minimal harm 2023-10-19

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-11-17

G · Actual harm 2022-08-03

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-13

F · Potential for more than minimal harm 2022-08-03

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2022-09-13

F · Potential for more than minimal harm 2022-08-03

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2022-09-21

F · Potential for more than minimal harm 2022-08-03

F809 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2022-09-13

F · Potential for more than minimal harm 2022-08-03

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2022-09-13

F · Potential for more than minimal harm 2022-08-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-10-03

D · Potential for more than minimal harm 2022-08-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2022-09-13

D · Potential for more than minimal harm 2022-08-03

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2022-09-13

C · Minimal harm 2022-08-03

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2022-09-13

Penalties and ownership

What sits behind the stars

Ownership

Pc Hmh Opco Holdngs LLC

5% Or Greater Direct Ownership Interest · Organization

100% 8 facilities 2023-03-16
Grewal, Baljinder

Operational/Managerial Control · Individual

0% 13 facilities 2023-03-16
Levovitz, Yitz

Operational/Managerial Control · Individual

0% 13 facilities 2023-03-16
Matzliah, Menachem

Operational/Managerial Control · Individual

0% 1 facilities 2023-03-16
Mercado, Wanda

Operational/Managerial Control · Individual

0% 25 facilities 2023-03-16
Nasra, Magdy

Operational/Managerial Control · Individual

0% 2 facilities 2023-03-16
Pc Hmh Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 8 facilities 2023-03-16
Peace Capital Holdings LLC (De)

5% Or Greater Indirect Ownership Interest · Organization

0% 57 facilities 2023-03-16
Sms 2021 Trust

5% Or Greater Indirect Ownership Interest · Organization

0% 63 facilities 2023-03-16
Stein, Shalom

Corporate Officer · Individual

0% 83 facilities 2023-03-16

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Fines
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#3

Careone At Holmdel

Holmdel, NJ

5-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

Overall
5 / 5
Health
4 / 5
Staffing
4 / 5
Fines
$0

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