Complete Care at Bayshore LLC

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure staff responsible for the facility food and nutrition services necessary had the skills and competencies to ensure a) the facility was maintained in a clean and sanitary manner, b) the mechanical dish machine was functioning appropriately, c) menus were followed to ensure appropriate portion sizes were provided and recipes were utilized to ensure nutritional adequacy of the food served, and d) residents received appetizing meals. The deficient practice affected all residents who resided in the facility, placed the residents at potential nutritional risk, and at risk for potential foodborne illness. The evidence was as follows: Refer to: [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a process was in place to ensure that menus and recipes were followed and appropriate portion sizes were provided to the residents. This deficient practice was identified for 10 of 10 residents who attended a resident council meeting and for Resident #69 and Resident #75 reviewed for food, and was evidenced by the follwoing: On 5/3/26 at 7:30 PM, the surveyor interviewed Resident #69 and Resident #75 in their room. When asked about the meals both residents stated the food was not good the hot food was served cold and the food was disgusting. Resident #69 also stated they were on a puree diet. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure that foods were prepared utilizing standardized recipes and ensure that meals were provided to residents at an appetizing temperature. The deficient practice occurred for 10 of 10 residents who attended a residents council meeting, for 2 of 2 residents reviewed for food (Resident #69 and Resident #75) and affected the nutritional adequacy and consistency of all foods served and affected all residents who resided at the facility. The deficient practice was evidenced by the following: Based on observation, interview and document review it was determined that the facility failed to ensure that foods were prepared utilizing standardized recipes and ensure that meals were provided to residents at an appetizing temperature. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to ensure a) that equipment used to clean dishes and other kitchen items was utilized per manufacturer's specifications for temperature, b) foods were stored in a manner to prevent potential foodborne illness, and c) the kitchen environment and equipment was maintained in a clean and sanitary manner to prevent contamination from foreign substances and limit the potential for the development a foodborne illness. This deficient practice affected all residents who resided at the facility and was evidenced by the following: On 05/03/26at 6:28 PM-7:00 PM, the surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD) and observed the following: [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to maintain a comprehensive and documented Quality Assurance Program (QAPI) and a process was in place to demonstrate the facility made good faith attempts to identify and prioritize potential issues related to resident care and services, and to track and measure performance at QAPI. The deficient practice affected all residents that resided at the facility and was evidenced by the following: Refer to: F605, F607, F677, F 684, F689, F695, F755, F761, F800, F803, F804, F812, F919 On 05/08/26 at 9:43 AM, the surveyor requested the Quality Assurance Performance Improvement (QAPI) to bring in the documents from the Licensed Nursing Home Administrator (LNHA) so he may discuss with the survey team. On 05/08/26 at 11:04 AM, the LNHA and the Assistant LNHA (ALNHA) returned to discuss QAPI. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all residents had their call light easily accessible and functional. This deficient practice was identified for 2 of 2 residents reviewed on 2 of 4 resident units (B- Wing and Sub-Acute) reviewed for adequate staffing (Resident # 30 and Resident #86), and had the potential of placing all residents at risk for inability to receive assistance in a timely manner to meet their needs. The evidence was as follows: a. On 5/3/26 at 7:00 PM, the surveyor observed Resident #30 sleeping in a low bed and the call bell was not in reach of the resident, and a floor mat was to the right side of the bed. On 5/4/26 at 9:34 AM, the surveyor conducted an initial review of Resident #30's medical record which revealed the following: [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a safe, comfortable, and homelike environment was provided for residents who had actual and/or expressed concerns regarding linen shortage at the facility. This deficient practice had the potential to affect all residents at the facility and was evidenced by the following: On 05/06/2026 at 11:30 AM, the surveyor reviewed the Resident Council minutes which revealed concerns regarding linen shortage for the last 3 months. The following were documented in resident council minutes: 2/27/27 linen shortage, 3/26 needs more towel, 4/30, towel and linen shortage over weekend. The resident council minutes did not reflect that the concerns with the linen shortage were resolved. Following the Resident Council meeting, the surveyor interviewed 3 alert residents over the above concerns. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure residents were free from unnecessary medications and potential chemical restraints by ensuring that psychotropic drugs had documented adequate indications for use, were monitored and were necessary to treat a specific condition. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for unnecessary medication (antipsychotic drug use and a diagnosis of Alzheimer's/Dementia). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure dependent residents were provided with routine and appropriate incontinence care in a timely manner. This deficient practice was identified for 2 of 2 residents reviewed (Resident #120 and #159) for Activities of Daily Living and appropriate incontinence care. The deficient practice was evidenced by the following:a) On 5/3/26 at 8:40 PM, the surveyor toured the 600 Unit of the facility, Resident # 120 informed the surveyor that they had a Urinary Tract Infection (UTI) and it burned. Resident #120 further stated that incontinence care was not provided timely, sometimes it could take up to one hour for the staff to assist with incontinent care. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice 2 of 28 residents (Resident #7 and Resident #135) reviewed for quality of care. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documents it was determined that the facility failed to provide adequate supervision and implement specific and meaningful interventions to prevent a resident identified at high falls risks and assessed as being cognitively impaired from experiencing unnecessary falls. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #30), and was evidenced by the following. The evidence was as follows: A review of the facility policy titled; Fall Prevention Program, Date Implemented 1/2/25 revealed: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 3. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate care and services for residents who required oxygen therapy by failing to administer oxygen according to the physician order. This deficient practice occurred for 2 of 5 residents, including a resident (Resident # 53) with a history of aspiration pneumonia (inhaling food into lungs) and acute hypoxic respiratory failure and Resident #74 reviewed for respiratory therapy and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteRepeat DeficiencyBased on observation, interview, and record review, it was determined that the facility failed (a) to follow Physician Orders (PO) with regards to medications with parameters for 2 of 29 residents (Resident #14 and Resident #63) reviewed for medication management (b) to properly secure a medication in one (1) of four (4) nursing units, and C). accurate reconciliation and administration of narcotic medication with potential for drug diversion .This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to properly label, dispose of and store medications in 2 of 6 medication carts and 1 of 3 medication rooms. The deficient practices was evidenced by the following: On 5/7/26 at 8:55 AM, the surveyor inspected B-Wing medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed 2 unidentifiable tablets that were loose inside the medication cart. The surveyor also observed a Fluticasone propionate nasal spray with a used by date of 2/6/26. At that time, the surveyor interviewed LPN#1 who stated that the medication carts are cleaned daily and that any loose pills should have been discarded immediately in a pill buster (medication disposal system). LPN#1 also stated that any medication that is past it's used by date should be removed from the medication cart. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to have a process in place to ensure that consistent communication between the facility and the hospice provider occurred for the coordination of resident care. This deficient practice was identified for one 1 of 2 residents reviewed for hospice care (Resident #13) and the deficient practice was evidenced by the following:On 05/04/2026 12:10 PM the surveyor observed Resident #13 lying in bed watching television. Resident #13 stated that they were in no pain and comfortable. A review of Resident #13's Electronic Medical Record (EMR) revealed diagnosis of but not limited to; [...]

Inspectors wroteBased on interviews and document review, it was determined that the facility failed to have a system in place to ensure prior to hire, all employees were pre-screened to ensure that they had not been found guilty in a court of law of abuse, neglect, or misappropriation, or had findings entered into the state nurse aide registry or against a professional license, and b) a process was in place to maintain documentation to confirm an appropriate pre-screening had occurred for all contracted facility employees which including dietary. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis treatment (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times. This deficient practice was identified for 1 of 1 residents (Resident #14) reviewed for dialysis and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure a resident call bell was operationional. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #30) and was evidenced by the following: On 05/05/26 at 8:30 AM, the surveyor observed Resident #30 in bed and the Certified Nurse Aide (CNA) was at the bedside setting up the meal. On 05/05/26 at 8:45 AM, a subsequent interview with the CNA revealed that Resident #30 would get out of bed every other day, Monday, Wednesday and Friday, with a mechanical lift and 2-persons to assist. When asked the CNA if the resident could press the call bell, the CNA then placed the call bell in the resident's hand and instructed the resident to press the call bell. The resident then tried to press the call bell, and it was not functioning. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's clinical status regarding bladder function for one of five sampled residents (Resident (R) 1) reviewed for resident assessment. This failure had the potential to affect care planning, infection risk management, and the provision of necessary services.

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary for ventilator-dependent residents. This deficient practice was identified by the following:On 12/26/25, the surveyor requested a copy of the Facility Assessment (FA). On 12/30/25, the surveyor reviewed the FA dated completed 9/30/25. The FA under Part 1: Our Resident Profile indicated that the facility is licensed to provide care for 232 residents but did not specify that the facility has a license for 220 long-term care beds and 12 ventilator care beds. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner. This deficient practice has the potential to affect all residents, and the evidence was as follows: On 10/22/24 at 9:53 AM, the surveyor in the presence of the Food Service Director (FSD) and Regional Food Service Director (RFSD) toured the kitchen and observed the following: 1. The ice machine had stains, brown and tan debris on the outside and flap of the machine. The FSD stated, it should be cleaned daily. The FSD and RFSD both acknowledge that it looked dirty and was not cleaned. 2. There were two, thirty-two gallon waste receptacles that were not covered which exposed the two food preparation stations to the refuse. The stations were not actively being used. [...]

Inspectors wroteNJ Complaint # NJ169941 Based on interview, review of the closed medical record, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident was sufficiently prepared for a discharge from the facility by providing a prescription for an active antibiotic treatment. This deficient practice was identified for 1 of 2 residents reviewed for discharge (Resident #239), and was evidenced by the following: On 10/28/24 at 10:23 AM, the surveyor reviewed the closed medical record for Resident #239 which revealed the resident was admitted to the facility in 2023 and discharged from the facility in 2023. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses including but not limited to; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop an individualized comprehensive care plan for a resident with chronic pain. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #10), and was evidenced by the following: On 10/22/24 at 12:17 PM, during initial tour of the facility, the surveyor observed Resident #10 in bed with eyes closed. On 10/24/24 at 10:01 AM, the surveyor reviewed the medical record for Resident #10. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses which included but were not limited to; diabetes (high blood sugar), depressive disorder, and chronic pain syndrome. [...]

Inspectors wroteComplaint # NJ169671 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a history of falls while at the facility. This deficient practice was identified for 1 of 1 resident reviewed for falls (Resident #189), and was evidenced by the following: On 10/24/24 at 11:32 AM, the surveyor reviewed the closed medical record for Resident #189. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses that included but were not limited to; heart failure, difficulty in walking, surgical aftercare, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure recommendations by the wound care consultant were implemented to prevent the worsening of a pressure ulcer. This practice was identified in 1 of 2 residents reviewed for pressure ulcers (Resident #13), and was evidenced by the following: On 10/22/24 at 11:12 AM, during the initial tour of the facility, the surveyor observed Resident #13 in bed. The resident told the surveyor that they had a sore that opened. At that time, the surveyor did not observe a low air mattress (a mattress designed to prevent and treat pressure wounds) pump on the bed. The surveyor asked the resident if they were on a low air mattress or a specialty mattress and the resident replied, No, I don't know what they are doing. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the accountability of the narcotic shift count logs were completed; and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 2 medication carts reviewed for medication storage, and was evidenced by the following: During medication storage review on 10/24/24 at 10:39 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the Vent unit medication cart A's September and October 2024 Change of Shift - Controlled Substances Count Sheet (a shift-to-shift controlled substance and narcotics (narc) count sheet signed by the incoming and outgoing nurses each shift) which revealed the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medications. This deficient practice was observed in 1 of 4 medication carts reviewed for medication storage and labeling, and was evidenced by the following: On 10/24/24 at 10:39 AM, the surveyor observed the Vent nursing unit's medication cart A. The medication cart was kept at the nurse's station and was left unattended by the Licensed Practical Nurse (LPN #1) while she administered medication to an unsampled resident. On the cart's unlockable pull-out tray/drawer, was observed packets of individually wrapped medications stored and visible with the tray/drawer in the retracted position. Upon return of LPN #1, the surveyor reviewed the cart and observed the following unsecured medications in the tray/drawer: [...]

Inspectors wroteComplaint #: NJ00166783, NJ00171418, NJ00172419 Based on interview and record review on 03/28/24, 04/01/24, and 04/04/24, it was determined that the facility failed to follow acceptable standards of clinical practice related to a.) consistently documenting the administration of a medication in the electronic Medication Administration Record (MAR) and b.) consistently document that a treatment was completed in the electronic Treatment Administration Record (TAR) This deficient practice was identified for two residents reviewed (Resident #2 and Resident #3) and was evidenced by the following: 1.) Resident #2 was not at the facility; a closed record review was completed. [...]

Inspectors wroteC #: NJ00171641 Based on observation, interview, and review of medical records and other pertinent facility documentation on 2/14/24, it was determined that the facility failed to follow professional standards of clinical practice for a). the administration of medications and b.) following a physician's orders, and c). adhering to the facility's policy for using the Medication Administration Record for 1 of 3 residents (Resident #2) reviewed for medication administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteComplaint # NJ 00159893 Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately document the administration of medications in the electronic medical administration record (eMAR), b.) clarify duplicate physician's orders for an over-the-counter medication, aspirin 81 mg, and c). failed to obtain a medication for pain. This deficient practice occurred for 3 of 24 residents, (Resident #58, #112, and #220) reviewed for medication review. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observations, interviews, record review, and a review of pertinent facility documentation, it was determined that the facility failed to a). follow appropriate infection control practices for proper hand hygiene, b). ensure staff wore the appropriate personal protective equipment (PPE) for three residents who were on transmission-based precautions (TBP) (Resident #19, #56 and #378) c).ensure communication that all COVID-19 positive residents were communicated from shift to shift accurately (Resident #99) and failed to d). ensure that multiuse medical equipment was properly disinfected on 2 of 4 nursing units (A-unit and the 2nd floor subacute unit). The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to update and revise a Care Plan in a timely manner to include a fall intervention for 1 of 3 residents, (Resident #91), reviewed for falls. This deficient practice was evidenced by the following: On 10/4/23 at 1:04 PM, the surveyor observed Resident #91 sitting upright in a recliner across from the nursing station. The resident's eyes were closed, and he/she did not respond to the surveyor. The surveyor reviewed the medical record for Resident #91. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to dementia, difficulty walking, repeated falls, and fracture the of left pubis (either of a pair of bones forming the two sides of the pelvis). [...]

Inspectors wroteComplaint # NJ000162720 Based on interview and review of medical records, it was determined that the facility failed to to follow professional standards of clinical practice with respect to a.) clarifing a Physician's Order (PO) for Betadine solution 10% on admission, b.) accurately transcribe a PO for Betadine Solution 10% onto the Feburary 2023 electronic treatment administration (eTAR) and c.) document a wound treatment order as administered on 1/30/23 and 1/31/23. This deficient practice was identified for 1 of 8 residents (Resident # 372) reviewed for closed records. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on interviews, record review, and review of other facility documentation, it was determined that the facility failed to a.) ensure that a resident received the appropriate care to maintain a Peripherally Inserted Central Catheter (PICC) (a thin soft tube that is inserted into a vein in the arm for long-term intravenous (IV) antibiotics) consistent with professional standards of practice and b.) update the care plan for a resident with a PICC. This deficient practice was identified for 1 of 1 resident (Resident #30) reviewed for IV therapy. This deficient practice was evidenced by the following: The surveyor reviewed the Electronic Medical Record (EMR) for Resident #30. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in September of 2023 with diagnoses which included but was not limited to; [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to a.) ensure a physician's order was obtained for a resident receiving oxygen and b.) the care plan was updated to include the resident was receiving oxygen. This deficient practice was identified for 1 of 1 resident (Resident #111) reviewed for oxygen therapy. This deficient practice was evidenced by the following: On 10/04/23 at 12:43 PM, the surveyor observed Resident #111 awake and in bed, wearing oxygen via nasal canula. The oxygen concentrator was set at two liters per minute (LPM). The resident stated that they needed oxygen before their admission to the facility. The surveyor reviewed the medical record of Resident #111. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to accurately monitor a resident's hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) treatment access site. This deficient practice was identified for 1 of 1 resident (Resident #93) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/12/23 at 10:10 AM, the surveyor observed Resident #93 in bed. The resident was alert, oriented, and responded appropriately to the surveyor. The resident stated that he/she went to hemodialysis (HD) on Monday, Wednesday and Friday in the afternoon. The resident stated that the HD access site was in the right upper chest (the resident pointed to the area). [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents it was determined that the facility failed to provide adequate indications and documentation supporting the rationale for COVID-19 related medications for a resident who tested negative for COVID-19. This deficient practice was identified for 1 of 24 residents (Resident #99) reviewed during medical record review and was evidenced by the following: On 10/5/23 at 10:00 AM, the surveyor observed Resident #99, self-propelling in their wheelchair toward the bathroom. The resident was alert and oriented but did not want to be interviewed. The surveyor observed the resident's room which had no stop sign or isolation signage on the door or wall, and no personal protection equipment (PPE) bin located outside of the resident's room. The surveyor reviewed the medical record for Resident # 99. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a). secure medications in 1 of 4 nursing units inspected, b). secure medications in 1 of 4 emergency kits (E-kits) inspected, and c). properly label, store and dispose of medications in 3 of 10 medication carts and 1 of 4 medication rooms inspected. This deficient practice was evidenced by the following: 1. On 10/05/23 at 2:10 PM, the surveyor observed two bags containing medications on the A unit nursing station, no residents were in the vicinity. The two bags included the following medications: Eliquis (blood thinner), Tessalon (medication for coughing), Vitamin D (vitamin), Norvasc (blood pressure), Diltiazem (blood pressure), Tradjenta (diabetes), Carafate (stomach medication), Xarelto (blood thinner), Nadolol (blood pressure) and Sevelamer (phosphate binder). [...]

Inspectors wroteComplaint # NJ 00162720 Based on interviews and review of medical records, it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by not documenting pertinent clinical documentation on the resident's medical record for a resident who had a change in condition. This was identified for 1 of 8 residents (Resident # 372) reviewed for closed records. This deficient practice was evidenced by the following: On 10/16/23 at 12:57 PM, the surveyor reviewed the closed medical record for Resident # 372. [...]