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 Holiday City during CMS and state inspections, most recent first.
Failure to prevent elopement of a cognitively impaired resident: A resident with severe cognitive impairment and documented elopement risk exited a secured unit after a visitor used the keypad code to leave the unit. The resident followed the visitor to the lobby and then left the facility when the receptionist opened the front door, assuming both were visitors and not checking the elopement-risk photos posted at the desk. Police later found the resident disoriented about 1 mile away and returned the resident to the facility.
During meal service on one unit, food was not served at required temperatures, with hot foods falling below 135°F and cold foods exceeding 42°F by the time trays reached residents. Staff interviews and temperature logs confirmed the deficiency, which was identified during a complaint investigation.
A resident with severe cognitive impairment and multiple medical conditions was observed in the dining room with their back exposed due to an untied hospital gown. Nursing staff provided the meal tray without ensuring the resident was properly covered, resulting in a failure to maintain the resident's dignity as required by facility policy.
A facility failed to conduct a thorough investigation after a resident-to-resident altercation, collecting only limited statements from staff no longer employed and not interviewing other staff or residents present. Both residents involved were cognitively intact and had chronic medical conditions. The facility's policy requiring comprehensive documentation and investigation was not followed.
Two residents were affected by inaccurate MDS coding, including failure to document a fall with injury, incorrect reporting of pressure ulcers, and misrepresentation of pain management. One resident's fall and pressure ulcer status were not accurately reflected in assessments, while another resident's pain medication administration was not properly coded despite documented severe pain and daily Oxycodone use.
Two residents did not have comprehensive, person-centered care plans developed for their specific needs. One resident with a right shoulder fracture and pain after a fall during dialysis transport lacked a care plan for pain management, while another resident receiving daily insulin for diabetes had no care plan addressing diabetes or insulin use. Nursing staff and leadership confirmed these omissions.
A resident with diabetes mellitus was receiving insulin therapy as ordered by a physician, but the care plan was not updated to include this intervention. Both the UM and DON confirmed that insulin administration should have been documented in the care plan, but review of the records showed it was omitted.
Two residents receiving insulin did not have proper physician orders or documentation for blood glucose monitoring, and in one case, elevated blood sugar results were not communicated to the physician. Staff interviews revealed a lack of clarity regarding responsibility for initiating blood sugar checks, and facility policy requiring regular monitoring was not consistently followed.
Two residents did not receive medications as ordered by their physicians. One resident was not given several prescribed medications despite their availability, and another received a nasal spray incorrectly when an LPN failed to shake the bottle and administered multiple sprays in one nostril instead of following the order for one spray per nostril. The DON confirmed these were medication administration errors.
Failure to Prevent Elopement of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was cognitively impaired and identified as an elopement risk. On 4/22/2026 at about 8:00 PM, a visitor exited the secured unit by entering a code into a keypad, which allowed the resident to also exit the unit. The resident followed the visitor to the front lobby, where the receptionist enabled the front door to open, allowing the resident to leave the facility with the visitor. The receptionist stated that photos of residents at elopement risk were posted at the reception desk, but he did not check them because he assumed both individuals were visitors. The resident was later found by police about 1 mile away at 8:58 PM and was returned to the facility at 9:15 PM. The facility’s reportable event stated that police notified the facility that the resident was outside, and the police report documented that the resident appeared disoriented and could not state what city their home was in or where they lived. Resident #2 had diagnoses including metabolic encephalopathy, COPD, and acute kidney failure. The quarterly MDS dated 4/19/2026 showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. The elopement assessment identified the resident as at risk for elopement, noting that the resident had expressed a desire to leave or go home and displayed shadowing of staff or residents and hovering at exits. The care plan also documented a history of attempts to leave the facility and wandering aimlessly, with an intervention to make sure all staff were aware of the elopement risk.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food at appropriate temperatures on the Applewood Unit, as observed during a complaint investigation. On the day of observation, food temperatures were measured at the tray line prior to distribution, with hot foods ranging from 165 to 188 degrees and cold foods from 37 to 42 degrees. Meal trays were then transported to the unit, with some trays placed in an enclosed cart and others in an open cart. Upon serving the last tray from the open cart, temperatures were retaken and found to be below required standards: hot foods measured between 111 and 136 degrees, and cold foods between 48 and 53 degrees. The Dietary Manager confirmed that hot foods should be at least 135 degrees and cold foods no higher than 42 degrees, as per facility policy. Interviews with dietary staff revealed that there had been previous complaints from residents about receiving cold food, prompting the facility to begin weekly temperature checks. Despite these measures, the observed meal service did not meet the facility's own guidelines for food holding temperatures. The deficiency was identified through direct observation, temperature measurement, and staff interviews, confirming that food was not consistently served at safe and appropriate temperatures.
Resident Dignity Not Maintained During Dining
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of five out of 15, was observed in the dining room seated in a geri chair wearing a hospital gown that was untied in the back. This resulted in the resident's back being exposed to other residents, family members, and staff while the resident leaned forward to eat. The resident's medical history included heart failure, irregular heart rhythm, and anxiety disorder. During the meal service, a registered nurse provided the resident with a meal tray but did not tie the hospital gown or cover the resident with a blanket to prevent exposure. The facility's policy on promoting and maintaining resident dignity requires staff to protect and promote resident rights and treat each resident with respect and dignity. The failure to ensure the resident was properly covered while dining was confirmed by observation and staff interviews.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation following a resident-to-resident altercation involving two cognitively intact residents, both with chronic medical conditions including diabetes and anxiety-related disorders. The incident occurred when one resident struck another on the back while passing in the hallway, with no injuries reported. The facility's self-reported investigation included statements from the Administrator, a staff member who witnessed the event, and one resident, but lacked documentation from other staff present during the incident or from additional residents who could have been interviewed. Further review revealed that the statements collected were from staff no longer employed at the facility, and there was no evidence of follow-up regarding the aggressor's psychiatric or behavioral history, nor any documentation of the victim's emotional response to the incident. The facility's policy requires a focused and thorough investigation with complete documentation, which was not met in this case. The deficiency was identified through record review, interviews, and examination of the facility's investigation documentation.
Inaccurate MDS Coding for Falls, Pressure Ulcers, and Pain Management
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to falls, pressure ulcers, and pain management. For one resident with Alzheimer's disease, the significant change MDS assessment did not reflect a documented fall with injury that required hospital evaluation, and the quarterly MDS assessment incorrectly indicated the presence of three Stage 3 pressure ulcers when only one sacral pressure ulcer was documented in the medical record during the relevant period. These inaccuracies were identified through review of the electronic medical record, incident reports, and progress notes. For another resident admitted with a right hip fracture, the admission MDS assessment failed to accurately code pain management. The assessment indicated that the resident had not received any pain medication during the observation period, despite the Medication Administration Record showing daily administration of Oxycodone. The same assessment documented that the resident experienced frequent, severe pain, rating it as 10 out of 10. These discrepancies were confirmed by the Regional MDS Coordinator during an interview.
Failure to Develop Comprehensive Care Plans for Pain and Diabetes Management
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable goals and resident-specific interventions for two residents. One resident, admitted with end stage renal disease, anemia in chronic kidney disease, and diabetes mellitus, sustained a right shoulder fracture after falling from a stretcher during transport to dialysis. Despite this incident and the associated pain, there was no documentation of a care plan addressing the fracture or pain management for this resident. This was confirmed by the unit manager during an interview. Another resident, admitted with diabetes mellitus type 2 and receiving both short-acting and long-acting insulin, did not have a care plan that addressed diabetes management or insulin use. The resident was cognitively intact and had been administered insulin daily, as documented in the medical record. Interviews with nursing staff and the director of nursing confirmed that a care plan for diabetes and insulin use should have been developed but was not present in the resident's record.
Failure to Update Care Plan for Insulin Administration
Penalty
Summary
The facility failed to review and revise the care plan for a resident with diabetes mellitus who was receiving insulin therapy. Record review showed that the resident had an active physician order for Insulin Glargine to be administered subcutaneously at bedtime, and the Minimum Data Set (MDS) indicated that the resident had received insulin during the assessment period. However, the resident's care plan, dated after the insulin order was in place, did not document that the resident was receiving insulin at bedtime. Interviews with the Unit Manager and the Director of Nursing confirmed that insulin administration should have been included in the care plan. The omission was identified through review of the electronic medical record and staff interviews, which verified that the care plan did not reflect the resident's current insulin therapy as required.
Failure to Follow Professional Standards in Diabetic Management
Penalty
Summary
The facility failed to follow professional standards in the diabetic management of two residents. For one resident with diabetes mellitus, there was an order for Lantus insulin at bedtime, but the care plan did not document the insulin administration, and there was no documentation of blood glucose monitoring in the medical record. Laboratory results showed an elevated blood sugar level, but there was no evidence that the physician or nurse practitioner was notified. The physician progress note did not address diabetes management or insulin use, and no order for blood sugar monitoring was present. Interviews with staff revealed that blood glucose monitoring was not performed unless specifically ordered by a physician, and the physician acknowledged that daily blood sugar checks are standard but were missed in this case. For another resident with diabetes, insulin was administered daily, and fingerstick blood sugar monitoring was performed three times daily, but there was no physician order for this monitoring. Staff interviews indicated that the resident returned from the hospital without orders for blood sugar checks, and the physician stated that insulin orders should be accompanied by a sliding scale for blood sugar monitoring, but was unaware that such orders were missing. The facility's own policy required regular blood glucose monitoring for residents receiving insulin, but this was not consistently documented or ordered.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for medication administration for two residents. For one resident with chronic obstructive pulmonary disease, hypertension, and a history of cerebral infarction, physician orders were in place for several medications including Clopidogrel, Folic Acid, Lasix, and Prednisone. Although these medications were available in the facility's medication dispensing system, the resident did not receive them as ordered. Documentation indicated that staff were awaiting delivery, despite the medications being accessible, and there was no evidence that the required medications were administered or that appropriate steps were taken to address the missed doses. For another resident with schizophrenia, a medication pass observation revealed that an LPN did not follow the physician's order for Fluticasone nasal spray. The LPN failed to shake the medication bottle before administration and attempted multiple sprays in one nostril when the medication did not dispense, instead of administering one spray per nostril as ordered. The LPN also incorrectly stated that shaking the bottle was unnecessary. These actions were confirmed as errors by the Director of Nursing, who stated that the medication should have been shaken prior to administration and that the order for one spray per nostril should have been followed.
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Illustrative
What surveyors actually found near you
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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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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) |
|---|---|---|---|---|
| Community Medical Center Tcu | 0.5 mi | ★★★★★ | 0 | 0 |
| Complete Care At Arbors | 2.4 mi | ★★★★★ | 0 | 0 |
| Complete Care At Bey Lea, Llc | 2.8 mi | ★★★★★ | 13 | 0 |
| Hampton Ridge Healthcare And Rehabilitation | 3.2 mi | ★★★★★ | 9 | 0 |
| Childrens Specialized Hospital Toms River | 3.2 mi | ★★★★★ | 0 | 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.