Inspection Reports for Complete Care At Bey Lea, Llc
1351 Old Freehold Road, NJ, 08753
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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 regarding their health 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: 110
Capacity: 120
Deficiencies: 8
Oct 21, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations and a Life Safety Code Survey.
Findings
Deficiencies were cited related to medication administration, respiratory/tracheostomy care, pharmacy services, hospice services, staffing, life safety code violations including exit signage, fire extinguishers, smoking regulations, and HVAC maintenance. Corrective actions and education plans were initiated for all cited deficiencies.
Complaint Details
Complaint numbers NJ175730, NJ175969, NJ176781 were investigated during the recertification survey. Deficiencies were substantiated related to medication administration, respiratory care, and staffing.
Severity Breakdown
Level D: 5
Level F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide resident supplements as ordered, supplements were immediately administered once the facility was made aware. | Level D |
| Failed to obtain a physician's order for respiratory/tracheostomy care and develop a care plan for a resident. | Level D |
| Failed to ensure accurate ordering and receiving of narcotic medications; pre-signed DEA 222 forms were found. | Level D |
| Failed to maintain required minimum direct care staff ratios for CNA and RN staffing for multiple weeks. | Level D |
| Failed to provide adequate exit signage to clearly identify exit access paths. | Level F |
| Failed to replace 1 of 13 portable fire extinguishers and maintain them in accordance with NFPA 10 standards. | Level F |
| Failed to maintain non-smoking areas free from cigarette smoking and ash in mulch and planters. | Level F |
| Failed to maintain 2 of 9 resident room Packaged Thermal Air Conditioning units in proper working condition. | Level D |
Report Facts
Census: 110
Total Capacity: 120
Deficiencies cited: 8
Staffing Deficiency Days: 14
Required RN Staffing Hours: 457.44
Actual RN Staffing Hours Difference: -121.44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication administration and care plans for residents |
| Licensed Practical Nurse/Unit Manager #2 | Licensed Practical Nurse/Unit Manager | Interviewed regarding physician orders for residents |
| Director of Nursing | Director of Nursing | Named in corrective actions and education plans for medication administration and staffing |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided education on medication administration and hospice care |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing ratios and recruitment efforts |
| Maintenance Director/Designee | Maintenance Director/Designee | Responsible for audits of fire extinguishers and exit signage |
| Facility Educator | Facility Educator | Provided education on smoke free policy and other compliance areas |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Jul 23, 2024
Visit Reason
The inspection was conducted based on multiple complaints (NJ165027, NJ165643, NJ165884, NJ172668, NJ175547, & NJ175652) to assess compliance with regulatory requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance overall; however, a deficiency was identified related to failure to maintain the required minimum direct care staff-to-resident ratios for 28 of 28 day shifts, violating New Jersey staffing requirements.
Complaint Details
The visit was complaint-driven based on multiple complaint numbers. The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to staffing deficiencies. The facility must submit a Plan of Correction with completion dates. The deficiency was substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 28 of 28 day shifts. |
Report Facts
Census: 106
Deficient day shifts: 28
Required CNA staffing: 11
Actual CNA staffing: 7
Required CNA staffing: 14
Actual CNA staffing: 9
Inspection Report
Routine
Census: 108
Deficiencies: 0
Jul 22, 2024
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 2
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Apr 5, 2024
Visit Reason
The inspection was conducted as a complaint survey identified by Complaint #: NJ170479.
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
Complaint #: NJ170479; The facility was found compliant based on the complaint survey.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 5
May 21, 2023
Visit Reason
Recertification and complaint survey conducted to assess compliance with federal and state regulations including staffing ratios and PASARR screening.
Findings
The facility was found not in substantial compliance with several regulatory requirements including failure to complete updated PASARR screenings for residents with new diagnoses, failure to ensure medication and treatment carts were secured when unattended, failure to perform proper hand hygiene during care, and failure to meet minimum certified nursing assistant staffing ratios.
Complaint Details
Complaint intake numbers NJ158856, NJ158675, NJ155565 triggered the survey. The complaint investigation found deficiencies in PASARR coordination, medication cart security, infection control hand hygiene, and staffing ratios.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to complete a new PASARR level I for 1 of 3 residents reviewed when a new diagnosis was made after admission. | SS=D |
| Failed to ensure PASARR screenings were accurately completed prior to admission for 2 of 3 residents reviewed. | SS=D |
| Failed to ensure medication and treatment carts were secured while unattended for 1 of 5 medication carts and 1 of 2 treatment carts. | SS=D |
| Failed to ensure hand hygiene, including glove change, was performed during incontinence care for 2 residents observed. | SS=D |
| Failed to comply with applicable Federal, State, and local laws by not ensuring minimum certified nursing assistant staffing ratios were met on all day shifts for two consecutive weeks. | — |
Report Facts
Census: 97
Sample size: 34
Deficiency counts: 5
CNA staffing shortfall: 4
Staffing short days: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #16 | Licensed Practical Nurse | Named in medication cart security deficiency for leaving medication cart unlocked |
| LPN #17 | Licensed Practical Nurse | Named in medication cart security deficiency for leaving treatment cart unlocked |
| CNA #18 | Certified Nursing Assistant | Named in infection control deficiency for failure to change gloves and perform hand hygiene during care |
| CNA #13 | Certified Nursing Assistant | Named in infection control deficiency for failure to change gloves and perform hand hygiene during care |
| Social Worker (SW) | Responsible for reviewing and correcting PASARR screenings | |
| Staffing Coordinator | Responsible for nursing staff schedules and acknowledged staffing shortages | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding PASARR process, staffing ratios, and infection control expectations |
| Administrator | Facility Administrator | Interviewed regarding PASARR process, staffing shortages, and corrective actions |
| Infection Control Preventionist (ICP) | Provided education on hand hygiene and infection control |
Inspection Report
Life Safety
Deficiencies: 0
May 21, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
Complete Care at Bay Lea was found to be in compliance with the applicable life safety code requirements. The facility is a one-story building built in 1988 and divided into 11 smoke zones.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Sep 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145849 and NJ147416 regarding the facility's compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law. Staffing ratios did not meet minimum requirements for 12 out of 42 shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint Intake numbers NJ147416 and NJ145849. The complaint was substantiated by review of staffing reports and interviews, confirming staffing shortages on multiple shifts.
Deficiencies (1)
| Description |
|---|
| Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law. |
Report Facts
Census: 83
Shifts with staffing deficiencies: 12
Staff-to-resident ratios: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed on 09/21/2021 regarding staffing accuracy and difficulties covering shifts. |
Inspection Report
Routine
Census: 90
Deficiencies: 0
Jul 29, 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.
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
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 7
Apr 30, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Additionally, a COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with COVID-19 infection control regulations but had deficiencies related to food procurement, storage, preparation, and sanitation practices that could lead to foodborne illness. Deficiencies included uncovered and exposed food service equipment and utensils, improper storage of food items, and inadequate hand hygiene practices by dietary staff.
Severity Breakdown
SS=E: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Stand up mixer was uncovered and exposed in dry storage. | SS=E |
| Cleaned and sanitized china plates and hotel pans were uncovered and not inverted in storage. | SS=E |
| Plastic forks and lids were exposed due to damaged packaging. | SS=E |
| Dented can was improperly stored outside designated dented can area. | SS=E |
| Cooked pork loins were stored past their use-by date. | SS=E |
| Meat slicer was uncovered and exposed in prep area. | SS=E |
| Dietary aide performed inadequate handwashing, washing hands for only 5 seconds instead of 20 seconds. | SS=E |
Report Facts
Census: 83
Sample size: 20
Correction completion date: Jun 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding food storage and sanitation deficiencies | |
| Dietary Aide | Observed performing inadequate hand hygiene |
Inspection Report
Life Safety
Capacity: 120
Deficiencies: 0
Apr 30, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements during the COVID-19 Public Health Emergency.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements and in compliance with the minimum Life Safety Code requirements. The survey process was modified due to COVID-19, excluding approximately 50% of rooms and barriers from review.
Report Facts
Diesel fuel tank capacity: 475
Total licensed beds: 120
Backup power coverage: 25
Inspection Report
Routine
Census: 88
Deficiencies: 0
Mar 15, 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.
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
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 1
Feb 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to appropriately don and doff Personal Protective Equipment (PPE) when entering and exiting rooms of residents on Transmission Based Precautions. Deficient practices were observed in 4 of 11 residents reviewed on one nursing unit.
Severity Breakdown
Scope and Severity = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to appropriately don and doff Personal Protective Equipment (PPE) when entering and exiting rooms of residents on Transmission Based Precautions (TBP). | Scope and Severity = D |
Report Facts
Census: 93
Sample size: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Observed failing to properly don and doff PPE; re-educated by Director of Nursing |
| Director of Nursing/Infection Preventionist | Director of Nursing/Infection Preventionist | Provided interview and described PPE requirements and corrective actions |
Inspection Report
Routine
Census: 82
Deficiencies: 0
Dec 17, 2020
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.
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: 3
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