Complete Care at Holiday City

In the surveyor’s words

From the most serious findings on record at Complete Care at Holiday City, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 8, 2026

  Based on interviews, review of medical records, and review of other pertinent facility documents on 5/05/2026, it was determined that the facility failed to maintain a safe environment and to provide adequate supervision to prevent the elopement of a resident (Resident #2) who was assessed to be cognitively impaired and was identified as an elopement risk.Resident #2 exited their secured unit without staff knowledge and eloped from the facility on 4/22/2026 at approximately 8:01 PM. A visitor exited the secured unit at approximately 8:00 PM on 4/22/2026 by entering a code into a keypad allowing Resident #2 to also exit the unit. Resident #2 followed the visitor to the front lobby where the receptionist enabled the front door to open which allowed Resident #2 to exit along with the visitor. […]

• Actual harm, isolatedF684Mar 30, 2023

  NJ Complaint # 154756 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who sustained a fracture of the distal humerus (elbow) from a fall was readmitted to the facility from the hospital with a soft cast received appropriate care and services which included physician visits and assessments associated with a cast every shift that developed into a mechanical device pressure injury with the beginning stages of necrosis (death to all or most of cells in a tissue) which required wound care and antibiotic treatments. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2025

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain kitchen equipment in a clean and sanitary manner and b.) maintain nourishment room refrigerators in a clean and sanitary manner on 3 of 3 units and was evidenced by the following: On 4/22/25 at 9:48 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following: 1. The microwave had multi-colored dried stuck on debris on the interior ceiling of the unit. The FSD acknowledged it was not properly cleaned according to facility policy. 2. Two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. […]

• No harm, potential for more than minimal, patternF812Feb 13, 2025

  Based on observation, interview, and facility document review and in the course of a complaint investigation, the facility failed to serve food at the appropriate temperatures on one of three units (Applewood Unit) in the facility. This failure had the potential for residents to experience untoward effects from eating food not served at the appropriate temperatures. Findings include: An observation was conducted on 02/11/25 at 11:45 AM at which time temperatures were taken o food on the tray line. […]

• No harm, potential for more than minimal, patternF698Mar 30, 2023

  Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure residents who received dialysis treatments and were on fluid restriction diets received the appropriate amount of fluids daily in accordance with their physician's orders. This deficient practice was identified for 2 of 2 residents (Resident #35 and #80) reviewed for dialysis, and the evidence was a follows: 1. On 3/20/23 at 11:34 AM, the surveyor observed Resident #80's room, and the resident was not in his/her room. Certified Nursing Aide (CNA #1) informed the surveyor that Resident #80 was currently out of the facility at their dialysis appointment. […]