Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Bey Lea, Llc during CMS and state inspections, most recent first.
A resident with Parkinson's Disease and orthostatic hypotension had physician orders for BP checks without using the right arm and for Midodrine to be held when SBP was over 130. The EMR showed repeated BP readings taken from the restricted arm and multiple doses of Midodrine given when the SBP exceeded the ordered parameter. An LPN, a unit manager LPN, and the DON confirmed the orders were not being followed and that giving the medication outside the ordered parameters was a medication error.
A resident with severe cognitive impairment and total dependence on staff for ADLs was found during incontinence rounds to be wearing two incontinence briefs simultaneously, a practice acknowledged by an LPN as inappropriate. The resident's care plan and facility policy required proper incontinence care, but the observed double-briefing did not meet these standards.
Care Plan Missing Blood Pressure Limb Restriction: A resident with Parkinson’s disease and orthostatic hypotension had a physician order for BP checks in the right arm every shift, and the EMR showed BP was obtained from that arm. However, the resident’s comprehensive care plan did not include the right arm limb restriction. An LPN was unsure if it would be added, and the DON acknowledged the restriction was not on the care plan.
A resident with a nephrostomy tube was observed with a kinked tube, stained tape, urine draining into a bag placed at the bottom of the bed, and an undated dressing. Another resident with an indwelling catheter had a drainage bag observed without a privacy bag, and the TAR contained multiple blank entries for catheter care, infection monitoring, and urine output documentation. Staff and the DON confirmed that privacy bags were required and that urine output documentation was the nurse’s responsibility.
A resident with COPD, respiratory failure, dementia, and an order for O2 via nasal cannula at 3 L/min PRN SOB had oxygen tubing and the nasal cannula repeatedly observed on the floor next to the bed while the concentrator was not in use. The tubing and cannula were in direct contact with the floor and exposed to contamination, and an LPN and the DON both stated the equipment should be bagged when not in use to prevent contamination.
A surveyor found a 2 mL multi-dose vial of Methotrexate stored in a locked med refrigerator inside a biohazard bag without a resident name or dosage. An RN confirmed the vial should have been labeled, and an LPN stated it had been brought in by a resident's family but the resident had since been discharged. The DON later acknowledged the medication should have been identified with the resident's name and administration dosage.
Soiled linen was left in an untied plastic bag on the floor outside a resident’s room instead of being secured and taken to the soiled utility area. In a separate observation, an LPN/UM provided incontinence care to a resident on EBP for an MDRO while wearing gloves but no gown, even though the resident’s wet brief was exposed during high-contact care.
A resident with multiple diagnoses, including COPD, was observed receiving oxygen therapy without a physician's order or a care plan in place. Despite the facility's policy requiring orders for oxygen administration, the resident's medical records lacked such documentation. Interviews with staff confirmed the necessity of a physician's order for oxygen therapy, highlighting a deficiency in the facility's compliance with its policies.
The facility failed to ensure accurate ordering of narcotic medications, as a DEA 222 form was pre-signed by the MD before submission to the pharmacy. The DON confirmed the presence of a pre-signed form, which was against the facility's process. The MD acknowledged the error, stating it could lead to misuse for drug diversion.
A facility failed to initiate a hospice care plan for a resident with severe cognitive impairment, despite a physician order for hospice services. The care plan was only updated after an audit, revealing a misunderstanding among staff about care plan responsibilities. This deficiency was identified during a survey, showing non-compliance with facility policies.
The facility did not provide scheduled Health Shakes to nine residents. A surveyor found the shakes undelivered at the nurses' station, despite being labeled for morning distribution. An LPN confirmed they should have been distributed, and the DON stated they were scheduled for 10 AM. The facility policy requires specifying type, amount, and frequency for dietary supplements, which was not followed.
Failure to Follow Medication Parameters and Limb Restriction Orders
Penalty
Summary
The facility failed to follow physician orders for medication administration and vital sign monitoring for one resident. The resident had diagnoses including Parkinson's Disease and orthostatic hypotension, and the most recent MDS dated 8/26/25 showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The physician order required blood pressure to be taken on the left arm only, with no blood pressure on the right arm, every shift. The EMR showed multiple vital sign entries in which blood pressure was obtained from the resident's right arm on numerous dates in September 2025. The surveyor also reviewed the resident's MAR and found a physician order for Midodrine HCL 5 mg orally three times daily for hypotension, with instructions to hold the medication if systolic blood pressure was over 130. The MAR documented multiple administrations of Midodrine when the resident's systolic blood pressure was above 130 in July, August, and September 2025. During interviews, an LPN confirmed that Midodrine has patient-specific parameters and that giving it outside the physician's order would be a medication error. A unit manager LPN also confirmed that physician orders were to be followed and that administering Midodrine when blood pressure was above the ordered parameter would be a medication error. The DON, in the presence of regional leadership, acknowledged that the resident's Midodrine parameters and limb restriction were not being followed for numerous months despite staff and facility-wide education.
Inappropriate Double-Bruiefing of Dependent Resident During Incontinence Care
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including incontinence care, was found to be wearing two incontinence briefs at the same time. During incontinence rounds, an LPN/Unit Manager observed that the resident's incontinence brief appeared layered, and upon further inspection, it was confirmed that there was a second, dry incontinence brief inside the outer brief. The LPN/Unit Manager acknowledged that this was not appropriate care and indicated that a nursing aide from hospice care likely applied the briefs in this manner. The resident involved had a history of hemiplegia and hemiparesis following a stroke, aphasia, and severely impaired cognition, as indicated by a BIMS score of 2 out of 15. The resident was always incontinent of bowel and frequently incontinent of bladder, and was totally dependent on staff for personal hygiene, as documented in the care plan. Facility policy required that residents who are incontinent receive appropriate treatment to prevent infections and restore continence to the extent possible. The observed practice of double-briefing did not align with this policy.
Care Plan Missing Blood Pressure Limb Restriction
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for a resident with a right arm blood pressure restriction. Resident #36 had diagnoses including Parkinson’s disease and orthostatic hypotension, and the most recent comprehensive MDS dated 8/26/25 showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The physician order in the MAR directed vital signs, including blood pressure, to be taken in the right arm every shift, and the EMR showed that blood pressure was obtained from the resident’s right arm. A review of the resident’s individual comprehensive care plan did not identify the right arm limb restriction for blood pressures. During interview, the Unit Manager LPN stated she was not sure if it would be added but believed it would be a good idea. The DON, in the presence of the Regional Clinical Director, Regional Director of Operations, and Clinical Operations, acknowledged that the limb restriction was not on the care plan. The facility policy required the comprehensive care plan to include all services to be furnished and resident-specific interventions, and to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Nephrostomy Tube Care, Privacy Bag Use, and Urine Output Documentation
Penalty
Summary
The facility failed to maintain proper care for a resident with a right nephrostomy tube. During an incontinent round, the resident was observed lying in bed with the head of the bed elevated about 45 degrees, and the nephrostomy tube was kinked and secured with white tape stained with a brown substance. Clear, pale-yellow urine was draining into a bag positioned at the bottom of the bed, and the dressing over the insertion site was present but not labeled or dated. The resident had diagnoses including malignant neoplasm of the bladder and other artificial openings of the urinary tract, and the care plan identified the nephrostomy tube as a focus area with an intervention to monitor the tube. The facility also failed to ensure a resident's urinary drainage bag remained in a privacy bag. A surveyor observed the resident's urinary catheter drainage bag from the hallway with no privacy bag in place. The resident had diagnoses including urinary tract infection and sepsis, and the MDS identified an indwelling catheter with moderately impaired cognition. The resident's care plan included monitoring and documenting intake and output and monitoring and reporting signs and symptoms of UTI. In addition, the facility failed to document urinary catheter output as ordered for the resident with an indwelling catheter. The TAR showed multiple blank entries without nursing initials for catheter care, monitoring for signs and symptoms of infection, and urine output recording on several shifts. Staff interviews confirmed that urinary drainage bags were to be placed in privacy bags and that nurses were responsible for documenting urine output, and the DON acknowledged that urinary drainage bags are to be maintained in privacy bags and that physician orders should be completed in their entirety.
Unprotected Oxygen Tubing and Nasal Cannula
Penalty
Summary
The facility failed to contain respiratory equipment for a resident receiving oxygen therapy. Resident #65 was admitted with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, dementia, and major depressive disorder, and the MDS showed moderate cognitive impairment with substantial to maximal assistance needed for several activities of daily living. The resident had an active physician order for oxygen via nasal cannula at 3 L/min as needed for shortness of breath, and the care plan addressed oxygen therapy PRN SOB. During multiple observations, the resident’s oxygen concentrator was seen in the room but not in use, while the oxygen tubing and nasal cannula were repeatedly observed on the floor next to the bed, in direct contact with the floor and exposed to contamination. The tubing was dated 9/18/25. An LPN stated that the tubing and nasal cannula should not be on the floor and should be bagged when not in use because it was an infection control issue, and the DON stated that when not in use the oxygen tubing/nasal cannula should be bagged at the bedside to prevent contamination. The facility policy also stated that delivery devices should be kept covered in a plastic bag when not in use.
Improperly Labeled Methotrexate Stored in Medication Refrigerator
Penalty
Summary
The facility failed to store medical supplies in accordance with professional standards, as evidenced by the presence of an expired or improperly labeled medication in 1 of 2 medication storage rooms inspected. During inspection of the Star Unit medication storage room, a surveyor observed a 2 mL multi-dose vial of Methotrexate inside a biohazard reclosable plastic bag in the locked medication refrigerator. The vial did not have a patient's name or dosage on it, and the RN present confirmed that the medication should have the patient's name. The surveyor then interviewed the Unit Manager LPN, who stated that the medication had been brought in by a resident's family but that the resident had recently been discharged and was no longer in the building. The Unit Manager LPN confirmed that the medication should have been labeled with the resident's name. Later, the DON, in the presence of the Regional Clinical Director, Regional Director of Operations, and Clinical Operations, acknowledged that the medication should have been identified with a resident's name and administration dosage. The facility's policy on medications brought to the facility by the resident/family states that medications are to be administered according to physician's orders.
Soiled Linen Left on Floor and PPE Not Used During EBP Incontinence Care
Penalty
Summary
The facility failed to ensure soiled linens were handled appropriately on the nursing unit. During an incontinence tour, a surveyor observed an untied plastic bag containing soiled laundry on the floor next to the PPE bin outside an unsampled resident’s room. CNA #1 confirmed the bag contained the resident’s soiled laundry, completed hand hygiene, donned a gown and gloves, and assisted the resident in the bathroom while the bag remained on the floor outside the doorway. The resident was observed wearing a foley catheter connected to a right urine leg bag, and the resident’s incontinence brief was not soiled at the time it was exposed for observation. The facility also failed to ensure appropriate PPE was used during incontinence care for Resident #49, who was on Enhanced Barrier Precautions due to an MDRO. During observation, an LPN/UM performed care at the resident’s bedside, washed hands, and donned gloves but did not put on a protective gown. The LPN/UM pulled back the bed linen, exposed the resident’s green incontinence brief, turned the resident to the side, and unfastened the brief to expose the back, which was observed to be wet. The IP and DON stated that incontinence care is included in high-contact care activities requiring gown and gloves for residents on EBP, and the facility policy defined EBP as targeted gown and glove use during high-contact resident care activities.
Failure to Obtain Physician's Order and Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen and develop a care plan for a resident who was observed receiving oxygen therapy. The resident, who had diagnoses including dementia, anxiety disorder, diabetes mellitus, and chronic obstructive pulmonary disease, was seen receiving oxygen via nasal cannula on multiple occasions. However, a review of the resident's medical records, including the Order Summary Report, Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no physician's order for the supplemental oxygen. The resident's comprehensive care plan also lacked documentation for supplemental oxygen therapy. Despite the resident receiving oxygen therapy intermittently, there was no care plan developed to address this need. The facility's policy on oxygen administration requires that oxygen be administered under a physician's order, except in emergencies, and that a care plan should identify interventions for oxygen therapy based on the resident's assessment and orders. Interviews with facility staff, including Licensed Practical Nurses and administrative staff, confirmed that a physician's order is required for oxygen therapy. The facility's policy on comprehensive care plans mandates the development of a person-centered care plan within seven days after the completion of the comprehensive MDS assessment, which should include all care needs identified. The lack of a physician's order and care plan for the resident's oxygen therapy represents a deficiency in the facility's adherence to its policies and regulatory requirements.
Failure to Ensure Proper Narcotic Medication Ordering
Penalty
Summary
The facility failed to ensure accurate ordering and receiving of narcotic medications by not adhering to the required Federal narcotic acquisition forms (DEA 222 form) protocol. During a survey, it was discovered that one of the nine DEA 222 forms provided by the facility had been pre-signed by the Medical Director (MD) before submission to the provider pharmacy. The Director of Nursing (DON) confirmed the presence of nine DEA 222 forms in the facility's binder and acknowledged that one form had been pre-signed, which was against the facility's process. The process required the DON to complete the form and have the MD review and sign it before sending it to the pharmacy, ensuring no pre-signed forms existed. The surveyor attempted to interview the MD, who later confirmed via telephone that the facility used his DEA number to order narcotics. The MD explained that the DON filled out the DEA 222 forms, and he would sign them before sending them to the pharmacy. Upon being informed of the pre-signed form, the MD recalled signing the wrong form in haste and expected it to be destroyed. The MD acknowledged that pre-signed forms could lead to misdirection or misuse for drug diversion. The facility's policy and federal regulations require that the DEA 222 form be signed and dated by the purchaser on the day it is submitted for filling.
Failure to Initiate Hospice Care Plan
Penalty
Summary
The facility failed to initiate a person-centered care plan for hospice services for a resident with severe cognitive impairment, who was admitted with Alzheimer's disease. Despite having a physician order for hospice evaluation and treatment dated several months prior, the resident's care plan did not include hospice care until it was updated during an audit by the Regional Nurse Manager. This oversight was confirmed by the Director of Nursing, who acknowledged that the resident should have had a hospice care plan from the start of hospice services. Interviews with facility staff revealed a misunderstanding of responsibilities regarding the creation of hospice care plans. The Licensed Practical Nurse/Unit Manager believed that hospice was responsible for completing the care plan, while the facility's policy indicated that coordinated care plans should include both hospice and facility-provided care. The absence of a hospice care plan was identified during a survey, highlighting a deficiency in the facility's adherence to its own policies and procedures for residents receiving hospice services.
Failure to Administer Scheduled Health Shakes
Penalty
Summary
The facility failed to provide Health Shakes, a nutritional supplement, to nine residents as scheduled. On October 16, 2024, at 11:55 AM, a surveyor observed nine Health Shakes labeled with individual resident names sitting on a tray at the nurses' station on the Pleasant Plains Unit. These shakes were marked with the date and time for morning distribution. During an interview, the LPN/Unit Manager acknowledged that the shakes should have been distributed to the residents by that time. Further inquiry with the Director of Nursing revealed that the expectation was for the Health Shakes to be administered around 10 AM, as per the facility's schedule. The facility's policy on recording orders for dietary supplements specifies the type, amount, and frequency, but this was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Toms River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Garden Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 20 | 1 |
| Hampton Ridge Healthcare And Rehabilitation | 2 mi | ★★★★★ | 9 | 0 |
| Childrens Specialized Hospital Toms River | 2 mi | ★★★★★ | 0 | 0 |
| Community Medical Center Tcu | 2.3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Green Acres | 2.7 mi | ★★★★★ | 0 | 0 |
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