Complete Care At Bey Lea, Llc
Inspection Findings
F-Tag F0677
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
Number of residents sampled: 8Number of residents cited: 1Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate incontinence care for a resident who was dependent on staff for Activities of Daily Living. This deficient practice was identified for 1 unsampled resident (Resident #32) out of 8 residents observed during incontinence rounds on 2 of 2 nursing units and was evidenced by the following:On 9/23/2025 at 8:56 AM,
the surveyor performed incontinence rounds with Licensed Practical Nurse/ Unit Manager (LPN/UM) and observed Resident #32 in bed. LPN/UM exposed the resident's green incontinence brief from the front and stated that the resident was dry. LPN/UM #1 proceeded to close the brief. The surveyor noticed that the edge of the incontinence brief appeared layered. The surveyor asked LPN/UM to expose the back of the incontinence brief. The surveyor observed another dry green incontinence brief inside the outer green incontinence brief. The surveyor asked LPN/UM if applying 2 briefs on the resident was appropriate.
LPN/UM stated that it was not right and that they will educate the nursing aide from hospice care who probably did it. The surveyor reviewed the medical record of Resident #32.A review of the resident's admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) and aphasia (a language disorder that affects a person's ability to communicate).A review of the resident's most current quarterly Minimum Data Set (MDS), an assessment tool dated 9/6/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated severely impaired cognition. The MDS further assessed that the resident was dependent on staff assistance for toileting hygiene and that the resident was always incontinent of bowel and frequently incontinent of bladder.A review of the resident's Individualized Care Plan (ICP) included a problem area initiated on 8/21/2025, that the resident had incontinence of bladder and bowel and was totally dependent on staff for bathing, dressing and personal hygiene.On 9/24/2025 at 11:30 AM, during an interview with the survey team, the Director of Nursing (DON) stated that it is not appropriate for residents to wear 2 incontinence briefs because it can cause skin issues.A review of facility-provided policy titled Incontinence Care date implemented on 9/27/2024, included under Policy Explanation and Compliance Guidelines: 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. N.J.A.C. 8:39 - 27.1 (a)
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
COMPLETE CARE AT BEY LEA, LLC in TOMS RIVER, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TOMS RIVER, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPLETE CARE AT BEY LEA, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.