Cycle 1
Health 2024-10-09 · Fire 2024-10-09
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Linwood, NJ
Complete Care At Linwood, LLC
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
201 New Road And Central Ave, Linwood, NJ
(609) 927-6131
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
174
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1982-01-01
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
0.29
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.58
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.70
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,541
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.45% · Performance 22.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.63% · Performance 7.93% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.98
Baseline 53.29% · Performance 59.67% · Measure score 0.98 · Achievement 0.98 · Improvement 0
Adjusted total nurse staffing
0.57
Baseline 3.80 hours · Performance 3.24 hours · Measure score 0.57 · Achievement 0.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.77% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 370 · Observed rate 12.16% · Lower 95% interval 9.27% |
| Discharge to community | 60.76% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 383 · Observed rate 55.09% · Lower 95% interval 56.41% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 234 · Denominator 234 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 234 |
| Discharge self-care score | 69.38% |
53.69%
15.7 pts better
|
Numerator 111 · Denominator 160 |
| Discharge mobility score | 50.63% |
50.94%
0.3 pts worse
|
Numerator 81 · Denominator 160 |
| Pressure ulcers or injuries, new or worsened | 2.99% |
2.29%
0.7 pts worse
|
Numerator 7 · Denominator 234 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 7.93% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 215 · Observed rate 8.37% · Lower 95% interval 5.95% |
| Staff COVID-19 vaccination coverage | 2.87% |
8.2%
5.3 pts worse
|
Numerator 5 · Denominator 174 |
| Staff flu vaccination coverage | 95.17% |
42%
53.2 pts better
|
Numerator 197 · Denominator 207 |
| Discharge function score | 68.13% |
56.45%
11.7 pts better
|
Numerator 109 · Denominator 160 |
| Transfer of health information to provider | 98.86% |
95.95%
2.9 pts better
|
Numerator 174 · Denominator 176 |
| Transfer of health information to patient | 95.83% |
96.28%
0.5 pts worse
|
Numerator 23 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 20.18% |
25.2%
5 pts worse
|
Numerator 22 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.1
0.6 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · 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 | 1.5% |
2.4%
0.9 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.9% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
11.4%
9.1 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.8% · Q3 1.1% · Q4 1.2% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
4.6%
0.6 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.0% · Q3 8.8% · Q4 5.6% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 45.5% |
19.0%
26.5 pts worse
|
19.6%
25.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 44.2% · Q3 51.2% · Q4 56.8% · 4Q avg 45.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
13.5%
1.7 pts worse
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 13.3% · Q3 14.8% · Q4 18.0% · 4Q avg 15.2% · 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 | 13.9% |
9.8%
4.1 pts worse
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
9.7%
4.3 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.4% · Q3 6.7% · Q4 1.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · 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 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
15.9%
2.5 pts worse
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 17.0% · Q3 28.6% · Q4 16.4% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.0%
1.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.9% · Q3 6.2% · Q4 7.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
78.7%
10.7 pts better
|
81.7%
7.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.9% · Q2 88.3% · Q3 93.4% · Q4 90.7% · 4Q avg 89.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
8.2%
3.1 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 11.3% · Expected 11.2% · 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 2.1% · Q2 1.4% · Q3 0.8% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
80.1%
14.2 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
25.4%
3.1 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 22.6% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-19 · Fire 2023-05-19
10 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-03-30 · Fire 2021-03-30
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-05-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-30
D · Potential for more than minimal harm
2021-03-30
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-03-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-05-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-09
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 2024-11-15
E · Potential for more than minimal harm
2024-10-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-09
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 2024-11-15
D · Potential for more than minimal harm
2024-10-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-09
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 2024-11-15
D · Potential for more than minimal harm
2024-10-09
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 2024-11-15
D · Potential for more than minimal harm
2024-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
E · Potential for more than minimal harm
2023-12-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-29
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 2024-01-26
D · Potential for more than minimal harm
2023-12-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-26
F · Potential for more than minimal harm
2023-05-19
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-19
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 2023-06-30
E · Potential for more than minimal harm
2023-05-19
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 2023-06-30
D · Potential for more than minimal harm
2023-05-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-19
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 2023-06-30
D · Potential for more than minimal harm
2023-05-19
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 2023-06-30
E · Potential for more than minimal harm
2021-03-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-03-30
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 2021-05-14
Penalties and ownership
What sits behind the stars
Ownership
Peace Capital LLC
5% Or Greater Direct Ownership Interest · Organization
Stein, Shalom
5% Or Greater Indirect Ownership Interest · Individual
Eef Capital LLC
5% Or Greater Direct Ownership Interest · Organization
Schlaff, Benny
5% Or Greater Indirect Ownership Interest · Individual
Schlaff, Nachum
5% Or Greater Indirect Ownership Interest · Individual
Stein, Shalom
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Meadowview Nursing And Rehabilitation Center
Northfield, NJ
2-star overall rating with 2-star inspections with $49,754 in total fines with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Our Ladys Center For Rehabilitation & Healthcare
Pleasantville, NJ
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
United Methodist Communities At The Shores
Ocean City, NJ
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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