Inspection Reports for
Complete Care At Bey Lea, Llc

The facility was found deficient in multiple areas including failure to revise comprehensive care plans to reflect resident-specific restrictions, failure to provide appropriate incontinence care, improper catheter care and documentation, failure to contain respiratory equipment properly, medication errors related to blood pressure monitoring and medication administration, improper storage and labeling of medications, and inadequate infection prevention practices including handling of soiled linens and use of personal protective equipment.

The facility failed to provide appropriate incontinence care for one resident who was dependent on staff, evidenced by the resident wearing two incontinence briefs simultaneously, which is against facility policy and can cause skin issues.

Complaint NJ181912 (414550) and 2565108 involved allegations of failure to follow physician orders and document catheter care and ADLs for multiple residents. The complaint was substantiated based on interviews, record reviews, and facility documentation.

The facility failed to consistently document catheter care and ADLs for several residents, with multiple blank spaces on Treatment Administration Records (TARs) and Documentation Survey Reports indicating tasks were not completed or documented. Interviews with staff confirmed that undocumented care was considered not done, and oversight was insufficient.

Complaint numbers NJ175730, NJ175969, NJ176781 were investigated during the recertification survey. Deficiencies were substantiated related to medication administration, respiratory care, and staffing.

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.

The visit was complaint-related, triggered by allegations of failure to provide nutritional supplements, respiratory care, pharmaceutical services, and hospice care planning. The deficiencies were substantiated as evidenced by observations, interviews, and document reviews.

The facility was found deficient in multiple areas including failure to provide scheduled Health Shakes to residents, failure to obtain physician orders and develop care plans for supplemental oxygen for a resident, failure to ensure proper handling of DEA 222 narcotic acquisition forms, and failure to initiate a person-centered hospice care plan for a resident receiving hospice services.

The facility failed to provide nine Health Shakes to residents as scheduled; the shakes were found sitting on a tray at the nurses station instead of being delivered. Interviews with nursing staff confirmed the shakes should have been administered around 10 am as per facility policy.

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.

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 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.

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.

The facility failed to complete updated PASARR level I screenings for residents with new mental health diagnoses, failed to ensure medication and treatment carts were secured when unattended, and failed to ensure proper hand hygiene and glove changes during incontinence care for observed residents.

Complaint Intake numbers NJ147416 and NJ145849. The complaint was substantiated by review of staffing reports and interviews, confirming staffing shortages on multiple shifts.

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.

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.

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.