Complete Care at Bey Lea, LLC

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) follow a physician's order for medications with a parameter and acceptable professional standards of practice; and b.) follow physician's order to not take blood pressure on right arm due to limb restrictions for 1 of 38 residents (Resident #36) 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 wroteBased on observation, interview, and record review, it was determined that the facility failed to review and revise comprehensive person-centered care plan that identified furnished services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for a resident with a right arm blood pressure restriction. This deficient practice was identified for 1 of 38 residents (Resident #36) reviewed for care planning. This deficient practice was evidenced by the following: On 9/22/2025 at 10:04 AM, the surveyor reviewed the electronic medical record (EMR) for Resident 26. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteNumber of residents sampled: 8Number of residents cited: 1Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate incontinence care for a resident who was dependent on staff for Activities of Daily Living. This deficient practice was identified for 1 unsampled resident (Resident #32) out of 8 residents observed during incontinence rounds on 2 of 2 nursing units and was evidenced by the following:On 9/23/2025 at 8:56 AM, the surveyor performed incontinence rounds with Licensed Practical Nurse/ Unit Manager (LPN/UM) and observed Resident #32 in bed. LPN/UM exposed the resident's green incontinence brief from the front and stated that the resident was dry. LPN/UM #1 proceeded to close the brief. The surveyor noticed that the edge of the incontinence brief appeared layered. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) maintain proper care for a resident with a nephrostomy tube (NT) (a tube inserted through the skin into the kidney to divert urine to an external drainage bag); b.) ensure a resident's urinary collection bag remained in a privacy bag; and c.) document a resident's urinary catheter output as ordered by the physician. This deficient practice was identified for 2 of 3 residents (Resident # 25 and Resident # 115) reviewed for catheter care. This deficient practice was evidenced by the following: 1.) On 09/23/2025 at 9:00 AM, Surveyor #1 completed incontinent rounds with the Licensed Practical Nurse/Charge Nurse (LPN/CN) on the Sub-Acute Unit, Resident #115 was observed lying in bed with the head of the bed elevated approximately 45 degrees. [...]

Inspectors wroteBased on observation, interview, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to contain respiratory equipment, specifically a nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) in protective coverings for 1 of 1 resident (Resident #65) reviewed for respiratory care. This deficient practice was evidenced by the following:

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store medical supplies in accordance with professional standards, as evidenced by the presence of expired supplies. This deficient practice was identified in 1 of 2 medication storage rooms inspected. The deficient practice was evidenced by the following: On [DATE] at 10:25 AM, the surveyor inspected the Star Unit Medication medication storage room in the presence of Registered Nurse (RN #1) who advised that the nurses are responsible for maintaining the storage room. The surveyor observed inside the locked medication refrigerator a 2 milliliter (mL) multi-dose vial of Methotrexate (a medication used to slow the growth of certain cells) inside of a biohazard reclosable plastic bag. The medication did not have a patient's name or dosage. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) soiled linens were appropriately handled in the nursing unit and b.) appropriate Personal Protective Equipment (PPE) was utilized during incontinence round to a resident who required Enhanced Barrier Precautions (EBP), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of infection control practice. This deficient practice was identified for 1 unsampled resident (Resident #49) observed during incontinence tour and occurred on 1 of 2 resident units (subacute rehab unit), respectively and was evidenced by the following:Reference: [...]

Inspectors wroteComplaint #: NJ181912 (414550), 2565108,Based on interviews, record review and review of pertinent facility documentation on 8/21/25 and 8/25/25, it was determined that the facility failed to: follow Physician Orders and consistently document catheter care on residents on the Treatment Administration Records (TAR) in accordance with the professional standards of nursing practice. This deficient practice was identified for 3 of 5 residents (Resident #1, Resident #3 and Resident #4), reviewed for catheter care. This deficient practice is evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteC#: NJ181912 (414550), 2573201 Based on interviews, a review of the medical record, and other pertinent facility documents on 8/21/202 and 8/25/25, it was determined that the facility failed to provide documented evidence of care provided to residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5). The facility also failed to follow the Certified Nursing Assistant's job description, and its policy titled, Documentation in Medical Record for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows:1. [...]

Inspectors wroteC/O # NJ 175730 Based on observation, interview and review of other facility documentation, it was determined that the facility failed to provide resident Health Shakes (a nutritional supplement) for 9 of 9 Health Shakes observed for delivery. This deficient practice was evidenced by the following: On 10/16/2024 at 11:55 AM, on Pleasant Plains Unit, the surveyor observed nine (9) four (4) ounce Health Shakes with the individual resident names sitting on a tray on top of the nurses station. Each container was labeled with the resident name along with AM 10/16. During an interview with the surveyor on 10/16/2024 at 12:06 PM, the surveyor asked the Licensed Practical Nurse/Unit Manager (LPN/UM #1) why are the Health Shakes still sitting on the counter. She replied Thats a good question. [...]

Inspectors wroteBased on observations, interviews, and review of other pertinent facility documents, it was determined that the facility failed to obtain a physician's order for supplemental oxygen and develop a care plan for 1 of 1 resident (Resident #53) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/15/2024 at 10:39 AM during the initial tour of the facility the surveyor observed Resident #53 lying in bed and receiving oxygen via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). The oxygen concentrator was observed to be set at 2 liters per minute (L/min) and the oxygen tubing appeared to be dated 10/4/24. According to the admission Record, Resident #53 was admitted to the facility with the following but not limited to diagnoses: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications by failing to ensure and that the required Federal narcotic acquisition forms (DEA 222 form) were dated and signed as of the day it was submitted for filling for 1of 9 forms provided, and was evidenced by the following: On 10/16/24 at 10:03 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed one of the nine provided forms had been pre-signed by the facility's Medical Director (MD) prior to submission to the provider pharmacy for filling. The forms were as follows: Order form number: [...]

Inspectors wroteBased on observation, interview, review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to initiate a person-centered care plan for Hospice services. This deficient practice was identified for 1 of 2 residents reviewed for Hospice services (Resident #26) and was evidenced by the following: During the initial tour on 10/15/2024 at 10:59 AM, Resident #26 was observed lying in bed with their eyes closed. A review of the EMR on 10/15/2024 at 03:49 PM, revealed the following: According to the admission Record Resident #26 was admitted with diagnoses including but not limited to: Alzheimer's disease. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) level I for 1 (Resident #11) of 3 residents reviewed for PASARRs. Specifically, the facility failed to submit an updated PASARR level I when Resident #11 was diagnosed with bipolar disorder and unspecified psychosis after admission.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was accurately completed prior to admission for 2 (Resident #43 and Resident #91) of 3 residents reviewed for PASARRs.

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined that the facility failed to ensure medication and treatment carts were secured while unattended for 1 of 5 medications carts and 1 of 2 treatment carts.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined that the facility failed to ensure that hand hygiene, including glove change, was performed during incontinence care for 2 (Resident #7 and Resident #75) of 2 residents observed for incontinence care.