Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 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 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.
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.
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.
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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.