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 Bayshore Llc during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had an MDS assessment coded to show an indwelling urinary catheter, despite no documentation in physician orders, treatment records, or nursing notes indicating catheter use during the assessment period. A CNA had entered incorrect bladder-related information into the point of care system, and this data was used to complete the MDS without verification by the IDT, contrary to facility policy and RAI Manual requirements for multi-source, validated assessment data.
The facility's assessment failed to identify and address the specific services, procedures, and resources required for ventilator-dependent residents. The assessment did not specify the facility's ventilator care bed licensing, nor did it include ventilator-dependent residents in sections covering diseases, care needs, staff training, or equipment. Leadership confirmed the omission during interviews, stating that ventilator care was considered under general respiratory needs.
The facility failed to maintain kitchen equipment in a sanitary manner, with issues including a dirty ice machine, uncovered waste receptacles, and uncleaned cooking equipment. The FSD acknowledged non-compliance with cleaning policies, posing potential contamination risks.
A resident with severe impaired cognition was discharged from a facility without a prescription for clindamycin, an antibiotic needed for an ongoing infection treatment. The omission occurred due to a miscommunication, as the Nurse Practitioner mistakenly believed the antibiotic treatment was completed. The facility's Vice President Clinical acknowledged the error, confirming the resident did not receive their medication on time.
A facility failed to develop an individualized comprehensive care plan for a resident with chronic pain. Despite the resident's frequent pain and administration of pain medications, their care plan lacked a focus on pain management. The resident, who was cognitively intact, expressed the need for an appointment related to shoulder pain. The facility's leadership acknowledged the oversight, which violated their policy and regulatory requirements.
A resident with moderate cognitive impairment and multiple medical conditions experienced a fall in the facility. Despite the incident, the resident's care plan was not updated with new interventions as required by the facility's policy. The Vice President of Clinical confirmed that care plans should be reviewed and updated after a fall, indicating a deficiency in policy adherence.
A resident with a pressure ulcer did not receive a recommended low air-loss (LAL) mattress, as observed by surveyors. Despite a wound care consultant's recommendation and a physician's order for daily wound care, the facility's staff were unaware or unsure of the resident's use of a LAL mattress. The facility's Wound Care policy lacked guidance on implementing consultation recommendations, leading to this deficiency.
The facility failed to ensure proper accountability and documentation of narcotic shift count logs and controlled medication administration. Reviews revealed missing signatures and incomplete narcotic counts on shift-to-shift controlled substance count sheets for two medication carts. Additionally, a resident's clonazepam dose was not documented on the declining inventory log, although it was recorded in the electronic MAR. Staff interviews confirmed the lack of adherence to the facility's policy requiring two licensed nurses to account for controlled substances at each shift change.
A surveyor observed improper medication storage on an unattended medication cart in the Vent nursing unit. An LPN left the cart with unsecured medications, including Eliquis and midodrine HCl, visible on an unlockable tray. The DON confirmed that medications should always be secured, aligning with the facility's policy requiring locked storage accessible only to authorized personnel.
The facility failed to follow clinical practice standards by not consistently documenting medication and treatment administration in the MAR and TAR for two residents. This included missing documentation for tube flushes and wound care treatments, with no records to confirm that the care was provided. Interviews with staff confirmed the importance of proper documentation for accountability and continuity of care.
Inaccurate MDS Coding of Bladder Function Due to Unverified CNA Documentation
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident's bladder function. A resident admitted with type 2 diabetes mellitus, chronic obstructive pulmonary disease, and stage 3A chronic kidney disease had an MDS with an Assessment Reference Date of 01/06/26 coded to indicate the presence of an indwelling urinary catheter. Review of the resident's physician orders, treatment records, and nursing documentation in the electronic medical record showed no evidence that the resident had an indwelling urinary catheter during the assessment period. During an interview, the Regional Nurse Clinical Supervisor reported that a CNA had entered incorrect information into the point of care system, and this inaccurate information was then used to complete the MDS without verification. Facility policy on MDS 3.0 Completion required that all disciplines follow the RAI Manual guidelines, which state that accurate assessments must be based on information collected from multiple sources covering the same observation period and validated for accuracy by the interdisciplinary team. These steps were not followed, resulting in the inaccurate coding of the resident's bladder function on the MDS.
Facility Assessment Lacks Ventilator-Dependent Resident Planning
Penalty
Summary
The facility failed to ensure that its facility-wide assessment (FA) adequately identified and addressed the required services and procedures necessary for ventilator-dependent residents. Upon review, the FA did not specify that the facility was licensed for 12 ventilator care beds in addition to 220 long-term care beds, nor did it include ventilator-dependent residents under the sections for diseases/conditions, resident support/care needs, staff training/education and competencies, or physical environment and equipment needs. The FA only referenced general respiratory conditions such as COPD, pneumonia, asthma, and respiratory failure, but did not specifically mention ventilator dependency or related requirements. During interviews, facility leadership confirmed that the FA was current but could not identify any vent-specific or related assessments within the document. When asked, the Vice President of Clinical stated that ventilator care was covered under the general respiratory category, and the President of Operations asserted that federal regulations do not require specific mention of ventilator care in the FA. The surveyor noted that the omission of ventilator-specific planning, licensing, and resources in the FA constituted a deficiency, as the facility did not comprehensively address the needs of ventilator-dependent residents as required.
Deficient Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary manner, as observed during a survey. The ice machine was found with stains and debris, and the Food Service Director (FSD) admitted it should be cleaned daily but was not. Two waste receptacles were uncovered, exposing food preparation stations to potential contamination. The eight-burner stove had accumulated burnt food and sludge, indicating non-compliance with cleaning policies. Additionally, a slicer marked as clean was found with crusted debris, and the can opener base had wipeable debris, both acknowledged by the FSD as not cleaned according to policy. The steam tables contained dirty water with floating debris, which the FSD admitted had not been cleaned as required. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged these concerns. The facility's Equipment Cleaning Policy outlined specific cleaning procedures for each piece of equipment, which were not followed, leading to potential cross-contamination and foodborne illness risks. The Ice Machines Sanitation policy also required daily cleaning of the ice machine's exterior, which was not adhered to.
Failure to Provide Antibiotic Prescription at Discharge
Penalty
Summary
The facility failed to ensure a resident was adequately prepared for discharge by not providing a prescription for an active antibiotic treatment. The resident, who had severe impaired cognition and was being treated for an infection related to a hip prosthesis, was discharged to an assisted living facility without a prescription for clindamycin, an antibiotic that was supposed to continue post-discharge. The resident's medical record indicated that clindamycin was administered regularly until the day before discharge, but the prescription was not included in the discharge documents. The deficiency occurred due to a miscommunication between the Nurse Practitioner and the facility staff, leading to the omission of the clindamycin prescription. The Nurse Practitioner mistakenly believed that both antibiotics prescribed to the resident had been completed, resulting in the failure to provide the necessary prescription upon discharge. This oversight was acknowledged by the facility's Vice President Clinical, who confirmed that the resident did not receive their medication on time, and there should have been no missed doses of clindamycin.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan for a resident with chronic pain, which was identified during a survey. The resident, who was admitted with medical diagnoses including diabetes, depressive disorder, and chronic pain syndrome, was observed by the surveyor in bed with eyes closed and later in a wheelchair speaking with the Unit Manager/LPN about needing an appointment for shoulder pain. The resident's medical records indicated frequent pain and the administration of pain medications, including oxycodone, as prescribed by a physician. However, the resident's comprehensive care plan did not include a focus area for pain management, despite the resident being cognitively intact and experiencing frequent pain. The surveyor's review of the facility's policies revealed that a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's needs. The Unit Manager/LPN confirmed that a resident with pain should have a pain management plan included in their care plan. During a meeting with the survey team, the facility's leadership acknowledged that the care plan should have been initiated when the resident began experiencing pain. This oversight was a violation of the facility's policy and regulatory requirements.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls, which was identified during a survey. The resident, who had moderate cognitive impairment and multiple medical diagnoses including heart failure and muscle weakness, experienced a fall on December 4, 2023. The fall occurred when the resident slid off their wheelchair in the bathroom, although no injuries were sustained. Despite the incident, the resident's individualized comprehensive care plan was not updated to include new interventions post-fall, which is a requirement according to the facility's policy. The facility's policy on managing falls and fall risks mandates that if falls recur despite initial interventions, staff should implement additional or different interventions or justify why the current approach remains relevant. However, the interdisciplinary team note dated December 5, 2024, indicated that a new intervention of frequent bathroom rounds was added, but this was not reflected in the resident's care plan. During an interview, the Vice President of Clinical confirmed that the care plan should be reviewed and updated with new interventions after a fall, highlighting the deficiency in the facility's adherence to its own policy.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to implement the wound care consultant's recommendations for a resident with a pressure ulcer, leading to a deficiency. The resident, who was cognitively intact and had a history of major depressive disorder, chronic pain, kidney stones, and cerebral infarction, was admitted with an unstageable pressure ulcer. The wound care consultant recommended the use of a low air-loss (LAL) mattress to offload pressure and prevent the worsening of the ulcer. However, during multiple observations by the surveyor, the resident was not provided with the recommended LAL mattress, and the care plan did not include this intervention. Despite the physician's order for daily wound care and the wound nurse practitioner's recommendation, the facility's staff, including the LPN and Unit Manager, were unaware or unsure of the resident's use of a LAL mattress. The facility's Wound Care policy did not address the process for implementing wound care consultation recommendations, contributing to the oversight. The Vice President of Clinical acknowledged the oversight and the need for staff education to follow wound care consultant recommendations.
Deficiency in Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs and accurately document the administration of controlled medications. During a review of medication storage, it was found that the shift-to-shift controlled substance count sheets for two medication carts had numerous missing signatures from both incoming and outgoing nurses. Additionally, the narcotic counts were not recorded for several shifts, indicating a lack of proper documentation and accountability for controlled substances. Further investigation revealed that a resident's Controlled Drug Administration Record log was incomplete, as the 9:00 AM dose of clonazepam was not signed out on the declining inventory log. An LPN admitted to administering the medication but failing to document it on the log, although it was recorded in the electronic Medication Administration Record. This oversight was acknowledged by the LPN, who confirmed that the declining inventory logs should be completed upon dispensing medication to maintain accurate narcotic counts. Interviews with facility staff, including the Director of Nursing and the Vice President of Clinical, confirmed that the shift-to-shift narcotic count logs were not completed as required. The facility's policy mandates that two licensed nurses account for all controlled substances at the end of each shift, but this procedure was not consistently followed, leading to missing documentation and signatures on the narcotic count logs.
Improper Medication Storage on Unattended Cart
Penalty
Summary
The facility failed to properly store medications, as observed by a surveyor on the Vent nursing unit's medication cart A. The cart was left unattended by an LPN while administering medication to an unsampled resident. On the cart's unlockable pull-out tray, several packets of individually wrapped medications were visible and unsecured. These included medications such as Eliquis, midodrine HCl, memantine HCl, pravastatin sodium, oxybutynin chloride, levofloxacin, baclofen, metoprolol tartrate, and amiodarone HCl. Upon questioning, the LPN acknowledged that medications should not be left unsecured on the tray, as there was a risk of them being taken. The DON confirmed that medications should always be secured and locked, regardless of the residents' mobility status. The facility's Medication Storage policy, reviewed in November 2022, mandates that all medications be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. The VPC, along with the survey team, LNHA, and DON, confirmed that the medications should not have been stored unsecured on the cart.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to follow acceptable standards of clinical practice by not consistently documenting the administration of medications and treatments in the electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR). This deficiency was identified for two residents. Resident #2 had multiple instances where tube flushes were not documented in the MAR, despite having orders to flush the tube with water every six hours. The review of the MAR and progress notes for various months showed blanks on specific dates, and there was no documentation to confirm that the flushes were administered. The nursing staff responsible for these dates were not available for interview during the survey. Resident #3 had severe cognitive impairment and was at risk for pressure ulcers. The facility discovered a Stage II open wound on the resident's sacrum, and there were orders for wound care treatments, including the application of Santyl and Metrogel. However, the MAR and TAR revealed multiple instances where these treatments were not documented as completed. The review of the progress notes also did not show any documentation that the treatments were performed on the specified dates. The nursing staff responsible for these dates were not available for interview during the survey. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that it is the responsibility of the nurses to document the completion of care in the MAR and TAR. The DON emphasized the importance of signing the MAR and TAR for accountability and continuity of care. The facility's policy on charting and documentation also required that all services provided to residents be documented in their medical records. The failure to document the administration of medications and treatments led to the deficiency identified in the report.
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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.
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Nursing homes near Holmdel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anchor Care And Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Respiratory And Nursing Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Careone At Holmdel | 2.7 mi | ★★★★★ | 0 | 0 |
| Arnold Walter Nursing & Rehabilitation Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Complete Care At Madison, Llc | 2.9 mi | ★★★★★ | 14 | 0 |
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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.