Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Arbors during CMS and state inspections, most recent first.
The facility failed to follow infection control practices for a resident on transmission-based precautions. Despite a physician's order for contact isolation due to C-diff and MRSA, appropriate signage was not posted, and staff did not consistently use required PPE. Interviews revealed a lack of awareness and adherence to the correct precautions, leading to significant lapses in infection control protocols.
The facility failed to include oxygen therapy in the baseline care plan for a resident admitted with congestive heart failure, pulmonary hypertension, and chronic kidney disease. Despite the resident receiving oxygen therapy, the baseline care plan did not address this intervention, as confirmed by both the LPN and the DON.
The facility failed to obtain a physician's order and update the care plan for a resident's use of ace wraps to manage edema. Despite the physician's order for a compression stocking on the right leg, staff applied ace wraps to both legs and documented the use of the compression stocking in the TAR. Interviews confirmed the discrepancy, and the facility's policies were not followed, leading to a deficiency in care.
The facility failed to investigate a facility-acquired pressure ulcer for a resident with severe cognitive impairment and multiple diagnoses. Despite the presence of a pressure ulcer and treatment measures, no incident/accident reports were filed, indicating a lack of proper investigation and documentation as required by facility protocol.
A resident receiving oxygen therapy at 2 lpm via nasal cannula did not have a physician's order documented until several days after the therapy began. The facility's staff and policy confirmed that a physician's order is required for oxygen administration.
The facility failed to label, date, and store potentially hazardous foods appropriately, as observed during a kitchen tour. Two packs of hamburger buns with a past use-by date, an opened and undated bag of couscous, and an opened bag of instant nonfat dry milk with a past use-by date were found in the dry storage pantry. The FSD confirmed that all items should have been labeled and discarded earlier.
The facility failed to accurately document medical records for three residents, leading to deficiencies in care. For one resident, treatment for a pressure ulcer was not properly documented. For two other residents, an incident was not recorded in the progress notes, hindering communication and follow-up care. Staff interviews confirmed the importance of accurate documentation.
The facility failed to make survey results readily accessible to residents and visitors. During a resident council task, 4 out of 5 residents were unaware of the survey results' location. The survey book was eventually found in a cabinet behind the reception desk, indicating it was not readily accessible as required.
Failure to Follow Infection Control Practices for Resident on Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure that infection control practices for residents on transmission-based precautions (TBP) were followed, specifically for Resident #79. The resident was admitted with diagnoses including C-diff and MRSA. Despite a physician's order for contact isolation due to these infections, the facility did not post appropriate signage indicating contact isolation on the resident's door. Instead, signs for enhanced barrier precautions (EBP) were posted, leading to confusion among staff about the required personal protective equipment (PPE) protocols. This discrepancy was observed by the surveyor, who noted that staff were not consistently using gowns and gloves when providing direct care to the resident, as required by contact isolation protocols. Interviews with staff, including CNAs, LPNs, and the Infection Preventionist, revealed a lack of awareness and adherence to the correct TBP for Resident #79. CNA #2, for instance, was observed providing direct care to the resident without wearing an isolation gown, and admitted to not noticing the EBP sign on the resident's door. The LPN and Infection Preventionist confirmed that the resident should have been on contact isolation based on the physician's order, but this was not reflected in the signage or staff practices. The LPN also admitted to signing the Medication Administration Record (MAR) indicating adherence to contact precautions, despite the lack of proper signage and PPE use. The Director of Nursing (DON) acknowledged the confusion regarding the type of TBP for Resident #79, attributing it to conflicting orders for contact isolation and EBP. The DON confirmed that if the resident had an order for contact precautions, the sign on the door should have indicated this, and staff should have adhered to the order. The Infection Preventionist also noted that the order for contact isolation should have been discontinued if no longer necessary, but until then, staff should have followed the order. The failure to properly implement and follow infection control practices for Resident #79 highlights significant lapses in communication and adherence to protocols within the facility.
Failure to Include Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline person-centered care plan to meet a resident's medical needs, specifically for respiratory care. Resident #148, who was admitted with diagnoses including congestive heart failure, pulmonary hypertension, and chronic kidney disease, was observed receiving oxygen therapy at 2 liters per minute via nasal cannula. Despite this, the baseline care plan initiated for the resident did not address oxygen therapy as an intervention for the resident's respiratory needs. Interviews with the LPN/Unit Manager and the Director of Nursing confirmed that oxygen therapy should have been included in the baseline care plan but was not. The surveyor reviewed the facility's policy on baseline care plans, which mandates that a baseline plan of care to meet the resident's immediate needs be developed within 48 hours of admission. The policy specifies that the interdisciplinary team should review healthcare practitioners' orders and implement a baseline care plan that includes initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. The failure to include oxygen therapy in the baseline care plan for Resident #148 was a clear deviation from this policy, as confirmed by both the LPN/Unit Manager and the Director of Nursing.
Failure to Obtain Physician's Order and Update Care Plan for Edema Management
Penalty
Summary
The facility failed to follow professional standards of clinical practice by not obtaining a physician's order for the application of ace wraps to manage a resident's edema and not updating the care plan to reflect the use of these devices. Resident #64, who was admitted with diagnoses including diabetes mellitus, cellulitis, and edema, was observed wearing ace bandages on both lower extremities despite the physician's order specifying the use of a compression stocking on the right leg only. The resident confirmed that they were supposed to wear a compression stocking on the right leg and an ace wrap on the left leg due to a wound, but staff had been applying ace wraps to both legs instead of the prescribed compression stocking on the right leg. This discrepancy was not reflected in the physician's orders or the resident's care plan, and staff continued to document the application and removal of the compression stocking in the Treatment Administration Record (TAR) despite the resident not using it. Interviews with the LPN, CNA, LPN Unit Manager, and DON confirmed that the resident had been wearing ace wraps without a corresponding physician's order and that the care plan had not been updated to reflect this practice. The facility's policies on medication orders, physician orders, and care plans were not followed, leading to this deficiency. The DON acknowledged that the nurses should have notified the physician about the resident's refusal to wear the compression stocking and obtained an appropriate order for the ace wraps. The facility's failure to adhere to these professional standards resulted in a deficiency in the care provided to Resident #64.
Failure to Investigate Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly investigate a facility-acquired pressure ulcer for one resident. The resident, who was admitted with diagnoses including COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia, did not have any unhealed pressure ulcers upon admission. However, a progress note dated approximately one month later revealed an opened area on the left buttock, which was treated with Santyl and foam border gauze. The care plan was revised to include treatments and dressings as ordered by the physician. Despite these measures, the facility did not have any incident/accident reports for the resident for the relevant period, indicating a lack of proper investigation and documentation. Interviews with various staff members, including a CNA, LPN, LPN/Unit Manager, and the DON, confirmed that the facility's protocol required reporting and investigating facility-acquired pressure ulcers. The DON verified that the nurse who discovered the pressure ulcer should have initiated an incident report. The facility's policy on investigating and reporting accidents and incidents was not followed, as evidenced by the missing incident/accident report for the resident. This failure to investigate and document the pressure ulcer was a significant lapse in the facility's care and oversight procedures.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for Resident #148, who was observed receiving oxygen at 2 liters per minute (lpm) via nasal cannula on multiple occasions. The resident, who was admitted with diagnoses including congestive heart failure, pulmonary hypertension, and chronic kidney disease, confirmed that she received oxygen most of the time. However, a review of the medical records revealed that there was no physician's order for oxygen therapy documented until 05/02/2024, despite the resident receiving oxygen since at least 04/24/2024. Interviews with the Licensed Practical Nurse/Unit Manager (LPN/UM) and the Director of Nursing (DON) confirmed that a physician's order is required for oxygen therapy. Both acknowledged that the order should have been written on 04/24/2024 when the resident was first observed receiving oxygen. The facility's Oxygen Administration policy, updated in 10/2019, also mandates verifying a physician's order for oxygen administration. The deficiency was confirmed by the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team.
Failure to Properly Label, Date, and Store Food
Penalty
Summary
The facility failed to label, date, and store potentially hazardous foods appropriately, as observed during a kitchen tour by the surveyor in the presence of the Food Service Director (FSD). Specifically, two packs of hamburger buns with a past use-by date, an opened and undated bag of couscous, and an opened bag of instant nonfat dry milk with a past use-by date were found in the dry storage pantry. The FSD confirmed that all items should have been labeled with an opened date, used by date, and received date, and acknowledged that the items should have been discarded earlier. The Licensed Nursing Home Administrator (LNHA) stated that the FSD generally conducted a walk-through on Wednesdays to check for expired items, which should have been discarded and labeled by then. A review of the facility's policies on food storage, dry food, and dating and labeling revealed that all foods should be properly stored, labeled, and dated to ensure food safety. The policies also indicated that expired items must be discarded immediately, which was not adhered to in this instance.
Failure to Accurately Document Medical Records
Penalty
Summary
The facility failed to accurately document in the medical records for three residents, leading to deficiencies in care. For Resident #146, the facility did not properly document the treatment of a pressure ulcer. The resident was admitted with severe cognitive impairment and no pressure ulcers. However, a progress note later indicated a new pressure ulcer on the left buttock, and the treatment administration record (TAR) showed that the prescribed treatment was not signed off on two occasions. Interviews with staff confirmed that the TAR should not be left blank and that treatments must be documented accurately to ensure proper follow-up care. For Resident #147, the facility failed to document an incident involving another resident in the progress notes. The resident had severe cognitive impairment and was involved in an incident with Resident #245. Although the incident was recorded in the Facility Reportable Event (FRE) and incident reports, there were no corresponding progress notes in the electronic medical record (EMR) to inform other staff members of the event. Interviews with staff revealed that documenting incidents in the progress notes is crucial for communication and follow-up care. Similarly, for Resident #245, the facility did not document the same incident with Resident #147 in the progress notes. The resident had intact cognition and was involved in the incident, but there were no progress notes in the EMR to reflect this. Staff interviews confirmed that progress notes are essential for coordinating care and ensuring that all staff are aware of incidents and can monitor residents appropriately. The Director of Nursing (DON) acknowledged the oversight and confirmed that progress notes should have been documented for both residents involved in the incident.
Failure to Make Survey Results Accessible
Penalty
Summary
The facility failed to make survey results readily accessible to residents and visitors. During a resident council task, 4 out of 5 residents reported that they were unaware of the location of the most recent survey results. The surveyor reviewed the resident council meeting minutes, which indicated that the survey book was supposed to be in the reception area. However, upon inspection, the surveyor did not find the survey book in the reception area or at the reception desk. The Business Manager eventually retrieved the survey book from a cabinet behind the reception desk, indicating that it was not readily accessible as required. Further interviews revealed that the receptionist was unaware of what a survey book was, and the Regional Licensed Nursing Home Administrator acknowledged that the survey book might have been put away during recent renovations. Despite the Licensed Nursing Home Administrator's statement that residents were informed of the survey book's location monthly, the surveyor found that the book was not readily accessible. This deficiency was noted under N.J.A.C. 8:39-9.4(b).
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 346 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Toms River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aristacare At Manchester | 2.1 mi | ★★★★★ | 17 | 0 |
| Complete Care At Holiday City | 2.4 mi | ★★★★★ | 7 | 1 |
| Community Medical Center Tcu | 2.7 mi | ★★★★★ | 0 | 0 |
| Hampton Ridge Healthcare And Rehabilitation | 3 mi | ★★★★★ | 9 | 0 |
| Childrens Specialized Hospital Toms River | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Complete Care At Arbors.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.