Complete Care At Bey Lea: Daily Care Failures - NJ
The discovery happened during morning incontinence rounds on September 23, when an inspector accompanied a Licensed Practical Nurse and Unit Manager to check residents. The nurse initially exposed the front of Resident 32's green incontinence brief and declared the patient dry before moving to close it.
But the inspector noticed the brief's edge appeared layered.
When asked to check the back of the brief, the nurse found a second dry incontinence brief nested inside the first one. Asked if applying two briefs was appropriate, the nurse admitted it was not right and blamed a nursing aide from hospice care.
The resident had been admitted with hemiplegia and hemiparesis following a stroke, along with aphasia that affects communication ability. A September assessment revealed severely impaired cognition with a score of 2 out of 15 on the mental status exam. The resident was completely dependent on staff for toileting and hygiene, always incontinent of bowel and frequently incontinent of bladder.
The facility's care plan, initiated in August, specifically noted the resident's total dependence on staff for bathing, dressing and personal hygiene due to bladder and bowel incontinence.
During an interview the next day, the Director of Nursing confirmed that wearing two incontinence briefs is inappropriate because it can cause skin issues.
The facility's own incontinence care policy, implemented in September 2024, states that incontinent residents "will receive appropriate treatment to prevent infections and to restore continence to the extent possible."
Double-diapering creates multiple risks for nursing home residents. The extra layer traps moisture against skin, increasing the likelihood of breakdown and pressure sores. For residents who cannot communicate discomfort or reposition themselves, like Resident 32, the practice becomes particularly dangerous.
The violation occurred despite the facility having clear policies about proper incontinence care. Staff members responsible for the resident's intimate care either didn't know basic procedures or ignored them entirely.
The timing raises additional concerns. The resident had been at the facility since August, giving staff weeks to establish proper care routines. Yet on a routine morning check, a supervisor discovered care so fundamentally wrong that she immediately recognized it as inappropriate.
The nurse's quick deflection of blame to a hospice aide suggests the facility may not have adequate oversight of outside caregivers working with their most vulnerable residents. Hospice workers often provide specialized care, but basic incontinence management remains the nursing home's responsibility.
For a resident who cannot speak, move independently, or advocate for proper care, the double-diapering represents a complete breakdown of the facility's duty to provide appropriate assistance with activities of daily living.
Federal inspectors found the violation during complaint-driven inspection, suggesting someone had raised concerns about care quality at the facility. The inspection covered eight residents across two nursing units, with Resident 32 being the only one cited for this particular violation.
The case illustrates how easily basic care can fail when staff lack proper training or supervision. What should have been a routine incontinence check instead revealed care practices that violated both common sense and the facility's written policies.
Resident 32 remains dependent on the same staff who layered two briefs without apparent concern for the consequences. The stroke damage that brought the resident to Complete Care at Bey Lea means total reliance on others for the most basic human needs.
Nobody had checked properly before the inspector arrived.
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 2025-11-17 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 November 17, 2025.
The nurse initially exposed the front of Resident 32's green incontinence brief and declared the patient dry before moving to close it.
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.