Inspection Reports for Complete Care At Bayshore Llc
715 North Beers Street, NJ, 07733
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 138
Capacity: 232
Deficiencies: 8
Oct 29, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to preparation for safe and orderly transfer/discharge, comprehensive care plans, treatment and services to prevent pressure ulcers, pharmacy services, staffing, life safety code violations, and food safety. The facility failed to meet several regulatory requirements impacting resident care and safety.
Severity Breakdown
SS=D: 6
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure sufficient preparation and orientation for resident discharge, including obtaining prescriptions for discharge medications. | SS=D |
| Failed to develop and implement individualized comprehensive care plans for residents. | SS=D |
| Failed to ensure treatment and services to prevent and heal pressure ulcers. | SS=D |
| Failed to provide routine and emergency pharmacy services, including accurate medication administration and record keeping. | SS=D |
| Failed to maintain required staffing levels and ensure accurate staffing documentation. | — |
| Failed to ensure proper labeling, storage, and security of drugs and biologicals. | SS=D |
| Failed to maintain kitchen equipment and food service areas in a clean and sanitary manner. | SS=F |
| Failed to ensure fire safety code compliance including proper fire-rated door hardware and electrical system testing. | SS=F |
Report Facts
Census: 138
Total Capacity: 232
Sample Size: 31
Deficiency Count: 9
Staffing Ratios: Various CNA staffing numbers and ratios detailed for specific dates
Residents affected: 138
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 2
Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (NJ00166783, NJ00171418, NJ00172419, NJ00172427) regarding the facility's compliance with professional standards and staffing requirements.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to consistently document medication administration and treatment completion in electronic records for two residents reviewed. Additionally, the facility failed to maintain required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on multiple day shifts, violating New Jersey staffing regulations.
Complaint Details
The complaint investigation was based on complaint numbers NJ00166783, NJ00171418, NJ00172419, and NJ00172427. The facility was found not in substantial compliance with professional standards related to medication and treatment documentation and staffing ratios.
Severity Breakdown
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to consistently document administration of medication and treatments in electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #2 and Resident #3. | SS=E |
| Failure to maintain required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 28 of 28 day shifts reviewed. | — |
Report Facts
Census: 139
Sample Size: 11
Deficient CNA staffing days: 28
Required CNAs vs Actual CNAs: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding medication and treatment documentation responsibilities. | |
| Director of Nursing (DON) | Interviewed regarding importance of MAR and TAR documentation and accountability. | |
| Nurse Practitioner (NP) | Post-survey telephone interview confirming expectation for nurses to follow orders and document care. |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 2
Feb 14, 2024
Visit Reason
The inspection was conducted based on complaint NJ00171641 to investigate allegations related to medication administration and staffing ratios at Complete Care at Bayshore LLC.
Findings
The facility was found not in substantial compliance with professional standards for medication administration, including improper self-administration of medication by a resident and failure to follow physician orders and facility policies. Additionally, the facility failed to maintain required minimum staffing ratios for certified nurse aides on multiple day shifts.
Complaint Details
Complaint NJ00171641 was substantiated based on findings of medication administration deficiencies and staffing shortages.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow professional standards for medication administration, including allowing a resident to self-administer medication unsafely and improper documentation on the Medication Administration Record. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 13 of 14 day shifts. | — |
Report Facts
Census: 148
Sample Size: 3
Deficient CNA staffing days: 13
Required CNA staffing: 18
Actual CNA staffing: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Explained risks and benefits of self-administration to resident and involved in corrective actions | |
| LPN #1 | Licensed Practical Nurse | Gave medication to resident and left medication unattended at bedside |
| Administrator | Unaware of resident self-medication practice and involved in facility oversight | |
| Assistant Director of Nursing | Provided in-service training to LPN on proper medication administration |
Inspection Report
Routine
Census: 121
Capacity: 232
Deficiencies: 9
Oct 19, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and a Life Safety Code Survey.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, professional standards of care, parenteral/IV fluids, respiratory/tracheostomy care, dialysis, pharmacy services, resident records, infection prevention and control, and life safety code compliance. Deficiencies affected multiple residents and required plans of correction.
Complaint Details
Complaint numbers NJ00166610, NJ00166192, NJ00165057, NJ00162720, NJ00160299, NJ00159100, NJ00159893, NJ00157098 were investigated as part of this survey.
Severity Breakdown
SS=D: 6
SS=E: 2
SS=B: 1
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision not updated in a timely manner for residents. | SS=D |
| Services provided failed to meet professional standards of quality. | SS=D |
| Parenteral/IV fluids care deficient for one resident. | SS=D |
| Respiratory/Tracheostomy care and suctioning deficient for one resident. | SS=D |
| Dialysis care deficient for one resident. | SS=D |
| Pharmacy services failed to accurately document medication administration and failed to clarify duplicate physician orders for medications for three residents. | SS=E |
| Resident records not maintained accurately and completely, including medication administration records and medical records. | SS=B |
| Infection prevention and control program deficiencies including failure to ensure proper PPE use and hand hygiene. | SS=E |
| Life Safety Code deficiencies including failure to ensure fire rated door assemblies and smoke barrier penetrations were properly maintained. | SS=F |
Report Facts
Sample Size: 24
Residents affected: 8
Beds: 232
Current census: 121
Deficiency counts: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to care plan revision and medication administration findings. |
| Regional Registered Nurse | Regional Registered Nurse (RRN#1) | Interviewed and provided information on care plan and medication administration. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN#1) | Interviewed regarding medication administration and care plan updates. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Provided information on incident investigations and care plan revisions. |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Interviewed regarding pharmacy services and medication administration. |
Inspection Report
Life Safety
Census: 129
Capacity: 232
Deficiencies: 3
Oct 10, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 10/10/2023 to assess compliance with fire safety regulations including NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with fire safety requirements including improper fire-rated door hardware on stairway exit doors, unsealed penetrations in smoke barriers allowing smoke transfer, and failure to conduct required annual electrical outlet testing. These deficiencies had the potential to affect all 129 residents present.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire rated door assemblies for stairway exit doors were equipped with panic hardware not approved for fire exit doors. | SS=F |
| Penetrations in smoke barriers were not protected by materials capable of restricting smoke transfer, including holes with wires passing through. | SS=F |
| Electrical outlet testing was not completed annually as required by NFPA 99 Health Care Facilities Code. | SS=F |
Report Facts
Current occupied beds: 129
Total licensed capacity: 232
Number of stairway exit doors observed: 10
Number of smoke barrier penetrations observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed deficiencies related to fire door hardware and smoke barrier penetrations; educated on corrective actions | |
| Administrator | Interviewed and confirmed deficiencies related to fire door hardware, smoke barrier penetrations, and electrical outlet testing |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 1
Mar 14, 2023
Visit Reason
The inspection was conducted in response to Complaint #NJ162248 to investigate allegations related to staffing ratios at the facility.
Findings
The facility was found not in compliance with New Jersey minimum staffing requirements, failing to maintain the required direct care staff-to-resident ratios on 13 of 14 day shifts reviewed. The facility was cited for insufficient Certified Nurse Aide (CNA) staffing during the day shifts.
Complaint Details
Complaint #NJ162248 was substantiated as the facility failed to meet the mandated CNA staffing ratios on 13 of 14 day shifts between 02/26/2023 and 03/11/2023. The facility acknowledged the deficiency and implemented corrective actions.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. |
Report Facts
Census: 132
Staffing Deficits: 13
Required CNAs per shift: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to staffing deficiencies and corrective actions. | |
| Staffing Coordinator | Interviewed regarding staffing ratios and responsible for staffing audits. | |
| Licensed Nursing Home Administrator | Informed of deficient practice on 3/14/23. | |
| Regional Clinical Consultant | Responsible for in-servicing the Staffing Coordinator on State Regulation S 560 Staffing. | |
| Director of Clinical Services | Informed of deficient practice on 3/14/23. |
Inspection Report
Life Safety
Deficiencies: 9
Jul 27, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/27/2022 and 07/28/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be noncompliant with multiple Life Safety Code requirements including emergency lighting, fire rated door latching, hazardous area door self-closing devices, fire alarm system installation, sprinkler system coverage, portable fire extinguisher inspections, corridor wall openings, smoke barrier integrity, and essential electrical system maintenance.
Severity Breakdown
SS=F: 7
SS=E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide battery backup emergency light above 1 of 3 emergency generator transfer switches. | SS=F |
| One of ten exit stairwell doors did not positive latch to maintain two-hour fire rated construction. | SS=F |
| Failed to provide and maintain self-closing devices on doors to hazardous areas. | SS=E |
| Failed to provide fire alarm notification by audible and visible signals for 2 enclosed courtyards and failed to install supervised smoke detection in lobby and atrium areas. | SS=F |
| Failed to provide proper fire sprinkler coverage in shower rooms and main lobby area. | SS=F |
| Failed to perform and document monthly visual inspection for 3 of 32 portable fire extinguishers. | SS=F |
| Transfer grills were used in corridor walls on resident sleeping units, which is prohibited. | SS=F |
| Failed to maintain integrity of smoke barrier partitions; multiple holes with wires and cables found in smoke barrier walls. | SS=E |
| Failed to ensure remote manual stop stations for 2 emergency generators were installed. | SS=F |
Report Facts
Number of emergency generators: 3
Number of fire extinguishers: 32
Number of exit stairwell doors tested: 10
Number of hazardous storage areas inspected: 11
Number of smoke barrier walls inspected: 13
Number of enclosed courtyards lacking fire alarm notification: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Interviewed regarding emergency generators and deficiencies. | |
| Regional Director of Plant Operations | Participated in building tours and confirmed findings. | |
| Director of Maintenance | Responsible for corrective actions and ongoing audits. | |
| Administrator | Notified of findings at Life Safety Code exit conference. |
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 0
Jul 5, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ146751, NJ149912, NJ152884, and NJ153010.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
The survey was complaint-related with multiple complaint numbers cited. The facility was found compliant based on the complaint survey.
Report Facts
Sample Size: 11
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 2
Jun 9, 2021
Visit Reason
The inspection was conducted based on complaints NJ138818 and NJ139215 alleging noncompliance with food safety and infection prevention requirements.
Findings
The facility was found noncompliant with food procurement and sanitary meal service practices, specifically dietary staff storing straws and condiments in pockets during meal service, and failure to perform and encourage hand hygiene among residents and staff, posing risks of cross contamination and infection transmission.
Complaint Details
Complaint NJ138818 and NJ139215 triggered the survey. The complaint involved failure to comply with food safety and infection prevention standards, including improper storage of meal items by dietary staff and inadequate hand hygiene practices. The complaint was substantiated based on observations and interviews.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Dietary staff stored straws and condiments on self during meal service, risking cross contamination. | SS=E |
| Failure to implement an effective infection prevention and control program, including inadequate hand hygiene by dietary staff and failure to offer hand hygiene to residents before meals. | SS=E |
Report Facts
Residents observed: 17
Sample size: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Named in findings for storing straws and condiments in pocket during meal service and failure to perform hand hygiene. | |
| Infection Control Preventionist | Provided statements on infection control practices and training responsibilities. |
Inspection Report
Routine
Census: 151
Deficiencies: 0
Jan 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
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