Complete Care at Bey Lea: Undocumented Catheter Care - NJ
Federal inspectors found multiple gaps in documentation for Resident #4, who required specialized care for both a urinary catheter and a urostomy. The facility's treatment records showed blank spaces where nurses should have recorded completing tasks on specific dates in July and August 2025.
The missing documentation included catheter drainage bag changes, which facility policy required weekly on Thursday night shifts. Records showed no entry for the bag change ordered for August 28. Nurses also failed to document catheter drainage monitoring on August 6 and August 15 during day shifts, despite orders requiring this documentation every shift.
For the resident's urostomy care, treatment records showed blank spaces for July 2 on both day and as-needed shifts, and July 27 on the day shift. Progress notes for July and August contained no documentation for any of the missing dates.
"I do not have anything further in writing that proved the treatments were completed," the Director of Nursing told inspectors during an interview on August 25.
The Director of Nursing confirmed the blank spaces on treatment records and said nurses should have documented all ordered tasks to ensure proper resident care. She said documentation should be completed at minimum each shift.
A registered nurse working at the facility acknowledged the documentation gaps and made a stark admission: "There should be no blanks because we take care of the patients and if it was not documented, it was not done."
The nurse said the Unit Manager, Supervisor, and Director of Nursing were responsible for overseeing nurses to ensure documentation was completed.
The Unit Manager confirmed the blank treatment record entries and said there should be no gaps in documentation. "Staff should have documented because it is a medical record, it may have had an effect on the resident's well-being," the Unit Manager told inspectors.
Facility policy required catheter care every shift and as needed by nursing personnel. The policy, implemented September 1, 2024, stated the facility must ensure residents with indwelling catheters receive appropriate care while maintaining dignity and privacy.
The catheter care policy specifically required nurses to empty drainage bags every shift as needed and keep drainage bags covered at all times while in use.
A separate documentation policy implemented October 1, 2024, required each resident's medical record to contain "an accurate representation of the actual experiences of the resident" with complete, accurate, and timely documentation.
Licensed staff and interdisciplinary team members were required to document all assessments, observations, and services in residents' medical records. Documentation had to be completed at the time of service, but no later than the shift when care occurred.
The inspection revealed a fundamental breakdown in the facility's documentation system for critical medical treatments. Catheter care requires precise monitoring to prevent infections and other complications that can be life-threatening for elderly residents.
Without proper documentation, supervisors cannot verify that residents received ordered treatments or identify patterns that might indicate developing problems. The blank spaces in treatment records created gaps in the medical record that could affect future care decisions.
The registered nurse's statement that undocumented care means care was not provided highlighted the significance of the missing entries. In healthcare settings, documentation serves as both a legal record and a communication tool between care providers across different shifts.
The facility's own policies recognized the importance of complete documentation, requiring entries to reflect residents' actual experiences and provide enough information to show progress through treatment.
Federal inspectors classified the violation as having potential for minimal harm affecting some residents. However, the systematic nature of the documentation failures across multiple dates and shifts suggested broader problems with treatment oversight at the facility.
The case of Resident #4 illustrated how documentation gaps can affect vulnerable patients requiring complex medical care. Residents with catheters and urostomies need consistent monitoring to prevent serious complications, making accurate record-keeping essential for their safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Bey Lea, LLC from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COMPLETE CARE AT BEY LEA, LLC in TOMS RIVER, NJ was cited for violations during a health inspection on August 25, 2025.
Federal inspectors found multiple gaps in documentation for Resident #4, who required specialized care for both a urinary catheter and a urostomy.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.