Complete Care At Bey Lea, Llc
COMPLETE CARE AT BEY LEA, LLC in TOMS RIVER, NJ — inspection on August 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with the surveyor on 08/25/2025 at 1:23 PM, the DON stated, I do not have anything further
08/25/2025 at 1:59 PM, the Registered Nurse (RN) confirmed the blanks on the TAR and stated, there should be no blanks because we take care of the patients and if it was not documented, it was not done.
The RN further stated that the Unit Manager, Supervisor, and the DON were responsible to oversight the nurses to ensure the documentations were completed.
During an interview with the surveyor on 08/25/2025 at 2:17 PM, the Unit Manager (UM) confirmed the blanks on the TAR and stated that there should be no blanks.
The UM stated that staff should have documented because it is a medical record, it may have had an effect on the resident's well-being. A review of a facility policy titled, Catheter Care, received from the DON at 1:23 PM, with a date implemented on 9/1/2024, revealed under Policy, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.
The policy also reflected under Policy Explanation the following:1.
Catheter care will be performed every shift and as needed by nursing personnel.2.
Privacy bags will be available and catheter drainage bags will be covered at all times while in use.8.
Empty drain bags every shift as needed. A review of a facility policy titled, Documentation in Medical Record, received from the DON at 1:23 PM, with a date implemented on 10/1/2024, revealed under Policy that, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.
The policy also reflected under Policy Explanation and Compliance Guidelines the following:1.
Licensed staff and interdisciplinary team members shall document all assessments, observation, and services provided in the resident's medical record in accordance with the state law and facility policy.2.
Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. NJAC 8:39-27.1(a)
315264 08/25/2025
Complete Care at Bey Lea, LLC 1351 Old Freehold Road Toms River, NJ 08753
During an interview with the surveyor on 08/25/2025 at 1:23 PM, the DON stated, I do not have anything further in writing that proved the ADLs were completed.
During an
blanks on the TAR and stated, there should be no blanks because we take care of the patients and if it was not documented, it was not done.
The CNAs should have documented.
The RN further stated that the nurses were responsible to oversight the CNAs and to ensure tasks were completed.
During an interview with the surveyor on 08/25/2025 at 2:08 PM, the CNA confirmed blanks on residents' ADL Sheets.
She stated that there should be no blanks on the ADL sheets because it is important to show documentation of the care that was provided to the residents throughout the shift.
She further stated that the CNAs should have documented the care provided by the end of the shift.
During an interview with the surveyor on 08/25/2025 at 2:17 PM, the Unit Manager (UM) confirmed the blanks on the TAR and stated that there should be no blanks.
The UM stated that staff should have documented because it is a medical record, it may have had an effect on the resident's well-being. A review of the residents' medical records showed no further evidence that the tasks mentioned above were completed. At the time of the survey, the facility could not provide evidence that the aforementioned tasks were completed. A review of a facility policy titled, Documentation in Medical Record, received on 8/25/2025 from the DON at 1:23 PM, with a date implemented on 10/1/2024, revealed under Policy that, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.
The policy also reflected under Policy Explanation and Compliance Guidelines the following:1.
Licensed staff and interdisciplinary team members shall document all assessments, observation, and services provided in the resident's medical record in accordance with the state law and facility policy.2.
Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. A review of the Certified Nurse Assistant under Major Duties and Responsibilities included but were not limited to:Assist residents with or performs activities of daily living for resident in accordance with care plans and established policies and procedures.Coordinates dining room services at assigned meal times, including set-up and clean up, meal tray delivery, feeding assistance, and documentation of meal intake.Delivers nutritional supplements to residents at assigned times and provides assistance as necessary to ensure intake.Completes flow sheets daily to indicate that the specified task was done. N.J.A.C.: 8:39-27.1(a)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.