Cape May Court House, NJ

Complete Care At Court House, LLC

5-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

144 Magnolia Drive, Cape May Court House, NJ

(609) 465-7171

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

120

Certified beds

Average residents

94

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1986-01-23

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

0.38

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

1.16

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

2.25

Nurse aide staffing · state 2.23 · national 2.35

Total nurse hours

3.79

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.54

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

3.32

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.17

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.76

CMS adjusted total nurse staffing hours

Case-mix index

1.38

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,586

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

Performance score

35.64

Composite VBP score used to determine payment impact.

Payment multiplier

0.9892

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.51

Baseline 17.61% · Performance 19.34% · Measure score 4.51 · Achievement 4.51 · Improvement 0

Healthcare-associated infections

5.89

Baseline 7.36% · Performance 6.08% · Measure score 5.89 · Achievement 5.89 · Improvement 4.94

Total nurse turnover

0

Baseline 62.38% · Performance 63.38% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

3.86

Baseline 3.54 hours · Performance 4.18 hours · Measure score 3.86 · Achievement 3.86 · Improvement 2.34

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.19%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 251 · Observed rate 10.76% · Lower 95% interval 8.54%
Discharge to community	59.23%	50.57% 8.7 pts better	Better than the National Rate · Eligible stays 261 · Observed rate 54.41% · Lower 95% interval 53.12%
Medicare spending per beneficiary	1.06	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 164 · Denominator 164
Falls with major injury	1.22%	0.77% 0.4 pts worse	Numerator 2 · Denominator 164
Discharge self-care score	94.5%	53.69% 40.8 pts better	Numerator 103 · Denominator 109
Discharge mobility score	88.07%	50.94% 37.1 pts better	Numerator 96 · Denominator 109
Pressure ulcers or injuries, new or worsened	3.05%	2.29% 0.8 pts worse	Numerator 5 · Denominator 164 · Adjusted rate 3.45%
Healthcare-associated infections requiring hospitalization	6.08%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 156 · Observed rate 4.49% · Lower 95% interval 3.66%
Staff COVID-19 vaccination coverage	2.31%	8.2% 5.9 pts worse	Numerator 3 · Denominator 130
Staff flu vaccination coverage	96.32%	42% 54.3 pts better	Numerator 157 · Denominator 163
Discharge function score	89.91%	56.45% 33.5 pts better	Numerator 98 · Denominator 109
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 40 · Denominator 40
Transfer of health information to patient	99.03%	96.28% 2.8 pts better	Numerator 102 · Denominator 103
Resident COVID-19 vaccinations up to date	5.68%	25.2% 19.5 pts worse	Numerator 5 · Denominator 88

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	2.1 1 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.1 About the same	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · 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	3.4%	2.4% 1 pts worse	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.9% · Q3 1.4% · Q4 1.4% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.0%	11.4% 8.4 pts better	11.4% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.8% · Q3 1.9% · Q4 1.8% · 4Q avg 3.0%
Percentage of long-stay residents who lose too much weight	1.5%	4.6% 3.1 pts better	5.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	24.8%	19.0% 5.8 pts worse	19.6% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 26.0% · Q3 23.5% · Q4 25.0% · 4Q avg 24.8%
Percentage of long-stay residents who received an antipsychotic medication	9.3%	13.5% 4.2 pts better	16.7% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.4% · Q3 10.2% · Q4 6.1% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	3.9%	9.8% 5.9 pts better	16.3% 12.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.4% · Q3 6.2% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.6%	9.7% 6.1 pts better	14.9% 11.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.6% · Q3 3.2% · Q4 5.3% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.7% 0.7 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.4%	15.9% 8.5 pts worse	19.8% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 29.2% · Q3 23.2% · Q4 13.7% · 4Q avg 24.4%
Percentage of long-stay residents with pressure ulcers	4.7%	6.0% 1.3 pts better	5.1% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.6% · Q3 8.5% · Q4 4.2% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.2%	78.7% 20.5 pts better	81.7% 17.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 98.6% · Q4 100.0% · 4Q avg 99.2%
Percentage of short-stay residents who had an outpatient emergency department visit	8.0%	8.2% 0.2 pts better	12.0% 4 pts better	Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.4% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.2%	1.2% 1 pts better	1.6% 1.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.8%	80.1% 16.7 pts better	79.7% 17.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.7%	25.4% 5.7 pts better	23.9% 4.2 pts better	Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 17.9% · Expected 21.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-13 · Fire 2025-03-13

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-02-02 · Fire 2023-02-02

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-02-10 · Fire 2021-02-10

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-13

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-03-13

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-04-25

F · Potential for more than minimal harm 2023-02-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-03-17

F · Potential for more than minimal harm 2023-02-02

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-03-17

F · Potential for more than minimal harm 2023-02-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-03-17

D · Potential for more than minimal harm 2021-02-10

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-03-11

Inspection history

Recent health citations

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

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2026-01-27

E · Potential for more than minimal harm 2025-03-13

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-13

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-13

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-13

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-13

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 2025-04-25

D · Potential for more than minimal harm 2025-03-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-25

F · Potential for more than minimal harm 2023-02-02

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 2023-03-17