Cycle 1
Health 2025-09-25 · Fire 2025-09-25
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Shrewsbury, NJ
Complete Care At Shrewsbury LLC
2-star overall rating with 2-star inspections with $56,925 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
89 Avenue At The Common, Shrewsbury, NJ
(732) 676-5800
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
140
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1972-03-14
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
0.52
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.18
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
1.49
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.34
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
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.90% · Performance 24.19% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.49% · Performance 9.22% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 54.55% · Performance 73.39% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.35 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 517 · Observed rate 10.83% · Lower 95% interval 8.98% |
| Discharge to community | 59.09% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 516 · Observed rate 54.65% · Lower 95% interval 54.39% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.7% |
95.27%
4.4 pts better
|
Numerator 327 · Denominator 328 |
| Falls with major injury | 0.61% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 328 |
| Discharge self-care score | 65.05% |
53.69%
11.4 pts better
|
Numerator 121 · Denominator 186 |
| Discharge mobility score | 58.6% |
50.94%
7.7 pts better
|
Numerator 109 · Denominator 186 |
| Pressure ulcers or injuries, new or worsened | 0.91% |
2.29%
1.4 pts better
|
Numerator 3 · Denominator 328 · Adjusted rate 0.83% |
| Healthcare-associated infections requiring hospitalization | 9.22% |
7.12%
2.1 pts worse
|
Worse than the National Rate · Eligible stays 364 · Observed rate 10.16% · Lower 95% interval 7.22% |
| Staff COVID-19 vaccination coverage | 4.17% |
8.2%
4 pts worse
|
Numerator 5 · Denominator 120 |
| Staff flu vaccination coverage | 98.48% |
42%
56.5 pts better
|
Numerator 130 · Denominator 132 |
| Discharge function score | 68.82% |
56.45%
12.4 pts better
|
Numerator 128 · Denominator 186 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 120 · Denominator 120 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 161 · Denominator 161 |
| Resident COVID-19 vaccinations up to date | 9.93% |
25.2%
15.3 pts worse
|
Numerator 15 · Denominator 151 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.1
0.3 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
93.0%
0.4 pts worse
|
93.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 89.1% · Q3 86.9% · Q4 98.6% · 4Q avg 92.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
97.2%
1.3 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
2.4%
0.7 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.1% · Q3 3.3% · Q4 2.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.4% |
11.4%
12 pts worse
|
11.4%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 44.4% · Q3 12.7% · Q4 18.2% · 4Q avg 23.4% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
4.6%
0.1 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.4% · Q3 5.6% · Q4 4.7% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
19.0%
3.4 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 27.4% · Q3 24.1% · Q4 18.5% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
13.5%
1.9 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 14.6% · Q3 11.4% · Q4 4.1% · 4Q avg 11.6% · 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 | 6.2% |
9.8%
3.6 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 13.6% · Q3 0.0% · Q4 6.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
9.7%
1.8 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.1% · Q3 5.8% · Q4 6.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 28.9% |
15.9%
13 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 20.8% · Q3 36.9% · Q4 33.1% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.0%
1.9 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 7.2% · Q3 1.6% · Q4 2.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.4% |
78.7%
6.3 pts worse
|
81.7%
9.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 61.7% · Q3 62.2% · Q4 76.9% · 4Q avg 72.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
8.2%
1.7 pts worse
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 8.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.6% |
80.1%
31.5 pts worse
|
79.7%
31.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
25.4%
3.2 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 27.9% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-03-10 · Fire 2022-03-10
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-10-25
F · Potential for more than minimal harm
2025-09-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-10-25
F · Potential for more than minimal harm
2025-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-25
F · Potential for more than minimal harm
2025-09-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-25
F · Potential for more than minimal harm
2024-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-30
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-19
D · Potential for more than minimal harm
2022-03-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-04-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-25
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 2025-10-25
E · Potential for more than minimal harm
2025-09-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-25
E · Potential for more than minimal harm
2025-09-25
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 2025-10-25
E · Potential for more than minimal harm
2025-09-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
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 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
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 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-01-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-22
D · Potential for more than minimal harm
2024-07-23
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-08-09
J · Immediate jeopardy
2024-05-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-30
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 2024-07-02
E · Potential for more than minimal harm
2024-05-30
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
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 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
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 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-19
E · Potential for more than minimal harm
2022-03-10
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 2022-04-10
D · Potential for more than minimal harm
2022-03-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-10
D · Potential for more than minimal harm
2022-03-10
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 2022-04-10
D · Potential for more than minimal harm
2022-03-10
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 2022-04-10
B · Minimal harm
2022-03-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-10
Penalties and ownership
What sits behind the stars
$53,780
2024-05-30
Fine
Fine · fine $53,780
Fine
$3,145
2023-05-15
Fine
Fine · fine $3,145
Fine
Ownership
Pc Hmh Opco Holdngs LLC
5% Or Greater Direct Ownership Interest · Organization
Gibbs, Jason
Operational/Managerial Control · Individual
Hoch, Robert
Operational/Managerial Control · Individual
Jurewicz, Stephen
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Pc Hmh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Sabella, Sabrina
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Atrium At Navesink Harbor, The
Red Bank, NJ
5-star overall rating with 3-star inspections with $82,560 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Redbank Center For Rehabilitation And Healing
Red Bank, NJ
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Gateway Care Center
Eatontown, NJ
5-star overall rating with 3-star inspections with $27,641 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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