Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Shrewsbury Llc during CMS and state inspections, most recent first.
The facility failed to serve hot foods at acceptable temperatures and did not follow its Test Tray Policy. A test tray and meals for nine residents were delivered with food temperatures below the required 135 degrees Fahrenheit. The FSD confirmed the deficiency and admitted that test trays were only conducted upon receiving complaints, contrary to the policy requiring weekly random test trays.
The facility failed to verify the certification of an agency CNA, whose certification was suspended, before she provided care to residents. This oversight violated the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, as the facility could not provide documentation of certification verification, despite claims of checking through the Online Public Registry.
A resident with severe cognitive impairment and behavioral disturbances frequently wandered into other residents' rooms, leading to physical altercations. Despite a care plan addressing wandering, the facility failed to implement effective supervision or transfer the resident to a more appropriate setting, resulting in ongoing incidents and a high risk of abuse.
The facility failed to provide bed hold policy information to four residents during hospital transfers, as required by policy. This oversight was confirmed by staff interviews and a lack of documentation in the residents' records.
The facility failed to provide scheduled showers to seven residents, as per their care plans, due to insufficient staff assistance. Residents reported not receiving showers for several weeks, and staff interviews revealed a lack of documentation confirming the provision of showers.
The facility failed to timely report an injury of unknown origin for a cognitively impaired resident and an abuse incident between two residents. The injury was discovered in the morning but reported to the State Agency the next day. In another case, a cognitively impaired resident wandered into another's room and was nearly struck, but the incident was not reported, and the resident continued to wander unsupervised.
The facility failed to investigate an incident where a cognitively impaired resident wandered into another resident's room, leading to a potential altercation. The cognitively intact resident admitted to being about to punch the intruding resident. Despite the facility's policy requiring thorough investigation of such incidents, the Director of Nursing confirmed that no investigation was completed, and the wandering behavior continued.
The facility failed to notify the Ombudsman of two residents' transfers to the hospital. One resident was taken to the ER for altered mental status and hypotension, and another for chest tightness and congestion. The usual procedure of completing a Transfer/Bed Hold notice was not followed, and the Business Office Manager could not locate the notices for these transfers.
A resident with dementia and a history of wandering behaviors was admitted to a facility, but their MDS assessment failed to reflect these behaviors and the use of a wander-guard bracelet. Despite documentation in the Admission Elopement Assessment and a physician's order for a Wander Guard, these details were omitted from the MDS. Facility staff confirmed the oversight, acknowledging that the resident's status should have been accurately documented.
The facility failed to present a baseline care plan within 48 hours for a resident with a fractured hip and intact cognition, and did not address the use of a wander-guard for another resident with dementia and wandering behaviors. The care plans did not include necessary interventions, confirmed by staff interviews.
A resident with COPD, emphysema, and asthma was receiving continuous oxygen therapy without a physician's order, and the nebulizer tubing was not changed as required. Observations showed that the oxygen tubing and nebulizer tubing had not been changed since a specified date, and the oxygen concentrator was unclean. Staff interviews revealed a lack of awareness and adherence to the facility's policy on oxygen administration.
A facility failed to assess and document the use of one-quarter bed rails for a resident with heart surgery and diabetes, who had intact cognition. Despite a physician's order for side rails, there was no documented assessment, informed consent, or care plan inclusion. Observations confirmed the resident's use of side rails without proper documentation, and the Administrator acknowledged the lack of policies for maintenance and safety checks.
The facility failed to properly label, date, and maintain cleanliness of food items in a second-floor refrigerator, with various items found unlabeled, undated, and expired. Additionally, a third-floor freezer had significant ice buildup due to a faulty door seal. The Food Services Director confirmed these deficiencies, which were not in compliance with the facility's policies on food storage and labeling.
The facility failed to provide adequate PPE for residents on Enhanced Barrier Precautions. A resident with cellulitis and another with wounds did not have gowns available on their isolation carts. Staff entered rooms with only gloves, acknowledging the lack of gowns and uncertainty about restocking responsibilities. The Unit Manager admitted to not restocking the carts.
Failure to Serve Hot Foods at Acceptable Temperatures
Penalty
Summary
The facility failed to serve hot foods at an acceptable temperature for residents and did not adhere to its Test Tray Policy. During a survey, it was observed that a test tray, along with meals for nine residents, was delivered to the second floor unit. The Food Service Director (FSD) was present and confirmed that the food temperatures were below the required 135 degrees Fahrenheit. Specifically, the baked ham was at 117.7 degrees, roasted potatoes at 123.9 degrees, and broccoli at 121.6 degrees. The FSD acknowledged that these temperatures did not meet the facility's standards for hot food service. Additionally, the facility's Test Tray Policy, which mandates weekly test trays at random mealtimes, was not followed. The FSD admitted that test trays were only conducted when a complaint was received, and there was no documentation of recent test trays or complaints. The facility's Food Temperatures and Holding Policy also required hot food to be served above 135 degrees Fahrenheit, which was not adhered to in this instance. The lack of compliance with these policies led to the identified deficiency.
Failure to Verify Certification of Agency CNA
Penalty
Summary
The facility failed to obtain and maintain a record of certification verification for a Certified Nursing Assistant (CNA) employed through an agency, which is a violation of their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program. This deficiency was identified during a review of the employee file for one of three sampled agency employees. The facility's policy requires conducting background checks and not employing individuals with findings of abuse, neglect, or exploitation. However, the facility did not verify the certification of CNA #1, whose certification had been suspended prior to her providing care to residents. During the survey, it was revealed that the facility's Human Resources and License Nursing Home Administrator claimed to verify certifications through the Online Public Registry. However, they could not provide documentation that CNA #1's certification was verified before she began working with residents. The New Jersey Department of Health confirmed that CNA #1's certification was suspended, which would have been evident if the verification had been conducted as claimed. This oversight indicates a failure to adhere to the facility's own policies and state regulations regarding employee certification verification.
Inadequate Supervision Leads to Resident Wandering and Altercations
Penalty
Summary
The facility failed to ensure adequate supervision of a resident with severe cognitive impairment, leading to incidents of wandering into other residents' rooms and resulting in physical altercations. The resident, who was admitted with moderate dementia and behavioral disturbances, had a history of wandering and entering other residents' rooms, which was documented in the facility's records. Despite being aware of the resident's behavior, the facility did not implement effective measures to prevent these incidents, resulting in a high likelihood of physical abuse either by or to the resident. The resident's care plan, initiated shortly after admission, identified wandering as a concern and included interventions such as educating caregivers, redirecting the resident, and providing structured activities. However, these interventions were not sufficient to prevent the resident from continuing to wander into other rooms, as documented in multiple nurse notes. The facility's staff frequently had to redirect the resident, who was often combative and verbally aggressive, but these efforts were not consistently effective. The facility's failure to adequately supervise the resident and prevent wandering led to multiple incidents, including one where the resident was found in another resident's bed and another where a physical altercation nearly occurred. Despite recommendations for the resident to be transferred to a dementia unit, no documented attempts were made to facilitate this transfer. The facility's inaction and lack of a consistent protocol for managing the resident's behavior contributed to the ongoing risk of abuse.
Removal Plan
- Placing Resident #60 on 1:1 supervision until appropriate placement was found.
Failure to Provide Bed Hold Policy to Residents
Penalty
Summary
The facility failed to provide copies of its bed hold policy to four out of five residents reviewed for hospitalization, creating a potential lack of information for residents and their responsible parties regarding their return to the facility. Resident 343 was admitted and later discharged to the hospital without evidence of receiving the bed hold policy. The facility administrator confirmed this oversight during an interview. Similarly, Resident 17 was transferred to the emergency room for altered mental status and hypotension, but there was no documentation of bed hold information being issued. The Licensed Practical Nurse (LPN) stated that the bed hold notice should be completed and provided to the resident or responsible party, but the Business Office Manager (BOM) could not locate the notices for Resident 17. Resident 38 was sent to the emergency room due to chest tightness and congestion, yet no documentation of bed hold information was found in the electronic medical record. The BOM confirmed the absence of these notices. Resident 27 experienced two hospital transfers due to uncontrolled high blood pressure and generalized weakness, but did not receive bed hold notices for either transfer. The Regional Nurse provided transfer notices but confirmed the lack of bed hold notices. The facility's policy requires that written information about bed holds be given to residents and their representatives prior to transfer, but this was not adhered to in these cases.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that seven out of eight residents received adequate assistance with obtaining weekly showers, as per their care plans. During a group meeting, residents expressed concerns about not receiving showers according to their preferences. The facility's policy mandates that residents be provided with care to maintain or improve their ability to carry out activities of daily living (ADLs). However, residents reported that there was insufficient staff available to assist them with showers, leading to several weeks without receiving one. The report details specific instances where residents did not receive showers as scheduled. For example, one resident, with intact cognition, required substantial assistance with showers but only received one shower in May 2024. Another resident, also with intact cognition, was scheduled for showers twice a week but had not received any since the beginning of May. Similar patterns were observed for other residents, some of whom had moderately impaired cognition and required assistance, yet did not receive showers as per their care plans. Interviews with staff, including a CNA and the Director of Nursing, revealed that showers were scheduled twice a week, but there was a lack of documentation confirming that these showers were provided. The Director of Nursing acknowledged the absence of documentation, and the Administrator suggested that CNAs might have forgotten to document the showers, despite residents voicing concerns about not receiving them.
Failure to Timely Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident who was severely impaired in cognition. The resident was found with bruising on her right hand, and upon inquiry, indicated that she had been harmed. The incident was reported to the police, and an investigation was initiated. However, the facility did not report the incident to the State Agency until the following day, despite the injury being discovered early in the morning. Additionally, the facility did not report an allegation of abuse between two residents in a timely manner. One resident, who was severely cognitively impaired, wandered into another resident's room and was found on the floor, seemingly in a defensive position. The other resident admitted to being about to strike the intruding resident. Despite this incident, it was not reported to the State Agency, and the cognitively impaired resident continued to wander into other residents' rooms daily. The facility's policy requires all such incidents to be reported to local, state, and federal agencies, but this was not adhered to in these cases.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of resident-to-resident abuse involving two residents. One resident, who had severe cognitive impairment with a BIMS score of three out of 15, wandered into another resident's room. The second resident, who was cognitively intact with a BIMS score of 15 out of 15, admitted to being about to punch the first resident for entering her room. The incident was not investigated, and the cognitively impaired resident continued to wander into other residents' rooms daily. The Director of Nursing confirmed that the facility did not complete a thorough investigation of the incident. The facility's policy on abuse, neglect, exploitation, and misappropriation requires all reports of resident abuse to be thoroughly investigated and documented. However, this policy was not followed in this case, as the incident was not investigated, and no interventions were put in place to prevent further occurrences.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman program of the transfer of two residents, R17 and R38, to the hospital, which was identified during a review of the facility's transfer form and interviews. For R17, the electronic medical record (EMR) showed that the resident was taken to the emergency room for altered mental status and hypotension, but there was no documentation of a transfer notice being issued. Similarly, R38 was sent to the emergency room due to chest tightness and congestion during a doctor's appointment, but there was no documentation of notification to the responsible party or attending physician regarding transfer rights. Interviews with staff revealed that the usual procedure involved the assigned nurse completing a Transfer/Bed Hold notice and providing it to the resident or their responsible party before hospitalization. However, the Business Office Manager, responsible for compiling and sending transfer notices to the Ombudsman, could not locate the notices for R17 and R38. The facility's policy required a transfer form to be prepared and the representative notified during emergency transfers, but this was not adhered to in these cases.
Inaccurate MDS Assessment for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident, specifically regarding wandering behaviors. The resident, identified as R29, was admitted with diagnoses including dementia with behavior disturbances, repeat falls, and unsteadiness on feet. Despite having a history of wandering behaviors documented in the Admission Elopement Assessment and a physician's order for a Wander Guard/Wander Elopement Device, these details were not included in the resident's admission MDS. This omission was identified during a review of the resident's records and confirmed through interviews with facility staff. Observations and interviews revealed that R29 was wearing a wander-guard bracelet, which was not documented in the MDS. The Unit Manager/Licensed Practical Nurse and the Director of Nursing both acknowledged that the resident's wandering behaviors and the use of a wander-guard bracelet should have been documented in the MDS. The RAI Manual, revised in October 2023, specifies that information should be validated for accuracy by the Interdisciplinary Team completing the assessment, which was not adhered to in this case.
Failure to Implement Baseline Care Plans and Address Wander-Guard Use
Penalty
Summary
The facility failed to discuss and present a baseline care plan within 48 hours of admission for one resident, identified as R84. This resident was admitted with a diagnosis of a fractured hip and had an intact cognition as indicated by a BIMS score of 14 out of 15. Despite the creation of a baseline care plan on 05/15/24, neither the resident nor their family member was informed about the care plan, which should have included details on activities of daily living, toileting, therapy frequency, and care goals. This oversight was confirmed by the Minimum Data Set Coordinator during an interview. Additionally, the facility did not adequately address the use of a wander-guard for another resident, identified as R29, who was admitted with dementia, behavior disturbances, repeat falls, and unsteadiness. Although the resident was identified as an elopement risk and had a physician's order for a wander-guard, the baseline care plan did not reflect this intervention. The Director of Nursing confirmed that the care plan failed to include the use of the wander-guard bracelet, despite the resident's history of wandering behaviors and the presence of the device during an observation.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R76, who was receiving oxygen therapy. R76 was admitted with chronic obstructive pulmonary disease (COPD), emphysema, and asthma. The facility did not have a physician's order for the continuous oxygen therapy that R76 was receiving. Additionally, the nebulizer tubing for R76 was not changed as per the physician's orders, which required it to be changed and dated every Wednesday on the 11-7 shift. Observations revealed that the oxygen tubing and nebulizer tubing had not been changed since 05/15/24, and the oxygen concentrator had a significant buildup of dust debris and was sticky to the touch. Interviews with staff, including an LPN and the Unit Manager, confirmed that the night shift was responsible for changing the tubing and cleaning the oxygen concentrator. However, the Unit Manager was unaware that the tubing had not been changed and that R76 was receiving oxygen therapy without a physician's order. The facility's policy on oxygen administration requires verification of a physician's order for oxygen therapy, which was not adhered to in this case.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of one-quarter bed rails for a resident, identified as R75, who was reviewed for bed rail use among 21 sampled residents. The resident had been admitted with diagnoses including heart surgery and diabetes and had an intact cognitive status with a BIMS score of 14 out of 15. Despite a physician's order for bilateral enablers (quarter) side rails for mobility, the facility's electronic medical records lacked documentation of an assessment for the use of these side rails. Additionally, there was no evidence that the risks versus benefits were discussed with the resident, nor was informed consent obtained. Observations over several days confirmed that the resident was using the side rails without a documented assessment or inclusion in the care plan. The facility's policy required informing the resident and family about the benefits and potential hazards of side rails and completing an assessment to determine the least restrictive means for the resident. However, during an interview, the Administrator confirmed the absence of an assessment for R75 and acknowledged the lack of policies and procedures for routine maintenance and safety checks of side rails on residents' beds.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling, dating, and cleanliness of food items stored in a refrigerator on the second floor nourishment room. During an observation, it was found that various food items, including to-go containers, beverages, and snacks, were not labeled or dated, and some were expired. The refrigerator shelves were also observed to be dirty and sticky. The Food Services Director (FSD) confirmed these observations and acknowledged that the food should have been labeled, dated, and expired items discarded. Additionally, the facility did not maintain a freezer on the third floor nourishment room in proper condition, as it was observed to have ice buildup throughout. The FSD confirmed that the freezer door did not seal properly, contributing to the ice accumulation. The facility's policies on receiving and storage, as well as foods brought by family or visitors, require that all foods be labeled, dated, and follow the first in, first out (FIFO) method, which was not adhered to in these instances.
Inadequate PPE Availability and Usage for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was readily available and appropriately used for residents on Enhanced Barrier Precautions (EBP). Specifically, for Resident 9, who was admitted with cellulitis of the right lower leg and required dressing changes with Medi Honey ointment, the isolation cart outside the room lacked gowns, which were necessary according to the EBP signage. Certified Nurse Aide 7 entered the room with only gloves, acknowledging the absence of gowns and uncertainty about who was responsible for restocking the isolation carts. Similarly, for Resident 140, who was placed on EBP due to wounds, the isolation cart outside the room was also missing PPE, specifically gowns. Licensed Practical Nurse 3 entered the room with only gloves to perform wound care, citing the resident's urgency to be discharged as a reason for not obtaining a gown. The Unit Manager/LPN later confirmed that she was responsible for ensuring the isolation carts were stocked and admitted to not restocking them on the day of the observations.
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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 Shrewsbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atrium At Navesink Harbor, The | 0.5 mi | — | 20 | 0 |
| Redbank Center For Rehabilitation And Healing | 1.3 mi | — | 0 | 0 |
| Shore Pointe Care Center | 3.8 mi | — | 1 | 1 |
| De La Salle Hall | 4 mi | — | 1 | 0 |
| Careone At Middletown | 4.6 mi | — | 0 | 0 |
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