Inspection Reports for
Complete Care At Bayshore Llc

The facility failed to ensure that the facility-wide assessment included ventilator-dependent residents and related equipment, services, and staff training. The assessment did not specify the licensed ventilator care beds or adequately address ventilator-specific planning and resources.

Complaint NJ169941 involved failure to provide an active antibiotic prescription upon discharge for Resident #239. Complaint NJ169671 involved failure to revise the comprehensive care plan after a fall for Resident #189.

The facility failed to ensure a resident was properly prepared for discharge with an active antibiotic prescription, and failed to revise the comprehensive care plan for a resident after a fall, resulting in minimal harm or potential for harm to a few residents.

The facility was found deficient in developing individualized care plans for pain management, implementing wound care consultant recommendations for pressure ulcers, ensuring accountability and documentation of controlled medications, properly storing medications securely, and maintaining kitchen equipment in a clean and sanitary manner.

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.

The complaint investigation was substantiated based on interviews and record reviews showing failure to document medication and treatment administration for two residents. Nursing staff interviews confirmed the expectation to document all care and that blanks indicated lack of documentation.

The facility failed to consistently document administration of medications and treatments for two residents, Resident #2 and Resident #3, as evidenced by multiple blanks in MAR and TAR records and lack of documentation in progress notes. Interviews with nursing staff confirmed that unsigned MAR and TAR entries indicated treatments or medications were not documented as completed.

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.

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.

The complaint investigation found that Resident #2 was self-medicating with Clobetasol Propionate Cream left at bedside by nursing staff, which was against facility policy. The Administrator and Director of Nursing were unaware of this practice. The resident applied medication only when remembered, and nurses signed the MAR without confirming application.

The facility failed to follow professional standards for medication administration, physician orders, and use of the Medication Administration Record for 1 of 3 residents reviewed. Specifically, medication was left at the resident's bedside for self-application without proper supervision, contrary to facility policy.

Complaint NJ00171641 was substantiated based on findings of medication administration deficiencies and staffing shortages.

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 NJ000162720 involved failure to follow clinical practice standards related to wound care orders and documentation for Resident #372. Complaint NJ00159893 involved failure to provide pharmaceutical services including medication administration documentation, duplicate orders, and medication availability for Residents #58, #112, and #220.

The facility failed to follow professional standards in clarifying and transcribing physician orders and documenting wound treatments for one resident. Additionally, the facility failed to provide pharmaceutical services meeting professional standards, including accurate medication administration documentation, clarifying duplicate orders, and obtaining medications for pain for three residents. There was also a failure to maintain accurate and complete medical records for a resident with a change in condition.

Complaint numbers NJ00166610, NJ00166192, NJ00165057, NJ00162720, NJ00160299, NJ00159100, NJ00159893, NJ00157098 were investigated as part of this survey.

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.

The facility was found deficient in timely updating care plans, accurate medication administration and documentation, proper infection control practices including PPE use and COVID-19 isolation communication, medication storage and labeling, and clinical documentation of resident condition changes.

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.

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.

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.

The facility was found deficient in multiple areas including failure to timely report and investigate injuries of unknown origin, failure to provide written bed hold notifications, incomplete care plans especially related to nutrition and weight changes, improper use of personal equipment by staff, inadequate personal care and hygiene for residents, insufficient and uncoordinated activity programs, delayed and inadequate pressure ulcer care, failure to monitor and respond to significant weight changes, improper positioning during tube feeding, inconsistent oxygen therapy management, inappropriate use and monitoring of psychotropic medications, failure to serve food at proper temperatures and times, and lapses in infection control practices including during wound care and food handling.

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.

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.

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.