Inspection Reports for Complete Care At Harborage Llc
7600 River Rd, NJ, 07047
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 214
Deficiencies: 1
Jan 21, 2025
Visit Reason
The inspection was conducted based on a complaint (Complaint #: NJ00182564) to determine compliance with federal and state regulations regarding staffing ratios and care standards.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing standards, failing to meet minimum staff-to-resident ratios on 8 of 14 day shifts. The facility submitted a plan of correction addressing staffing deficiencies and recruitment efforts.
Complaint Details
Complaint #: NJ00182564. The facility was found substantially compliant with federal requirements but deficient in state staffing ratios. No negative outcomes for residents were identified. All residents had the potential to be affected.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 8 of 14 day shifts. |
Report Facts
Census: 214
Deficient day shifts: 8
Staffing hours deficit: 18.5
Required CNAs on 01/05/25: 28
Actual CNAs on 01/05/25: 18
Required CNAs on 01/06/25: 27
Actual CNAs on 01/06/25: 20
Required CNAs on 01/07/25: 27
Actual CNAs on 01/07/25: 24
Required CNAs on 01/10/25: 27
Actual CNAs on 01/10/25: 23
Required CNAs on 01/11/25: 27
Actual CNAs on 01/11/25: 23
Required CNAs on 01/12/25: 27
Actual CNAs on 01/12/25: 20
Required CNAs on 01/14/25: 27
Actual CNAs on 01/14/25: 26
Required CNAs on 01/18/25: 27
Actual CNAs on 01/18/25: 18
Inspection Report
Complaint Investigation
Census: 186
Deficiencies: 3
Jan 8, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to a complaint visit regarding non-compliance with infection control regulations and failure to implement CDC and CMS recommended practices to prepare for COVID-19.
Findings
The facility was found not in substantial compliance with infection control requirements, resulting in an Immediate Jeopardy (IJ) situation due to failure to implement CDC and CMS guidance to prevent the spread of COVID-19 among residents and staff. Deficiencies included failure to perform recommended testing, contact tracing, isolation, and medication administration procedures. Staffing ratios also failed to meet state minimum requirements.
Complaint Details
The visit was complaint-related due to allegations of inadequate infection control practices during a COVID-19 outbreak. The facility was found not in substantial compliance and an Immediate Jeopardy situation was identified on 2024-01-03 related to failure to prevent spread of COVID-19 among residents and staff.
Severity Breakdown
Level K: 1
Level D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement CDC and CMS infection control guidance to prevent spread of COVID-19, resulting in Immediate Jeopardy. | Level K |
| Failure to provide pharmaceutical services ensuring accurate medication administration and documentation. | Level D |
| Failure to maintain minimum staffing ratios as required by New Jersey regulations. | — |
Report Facts
Census: 186
Sample Size: 16
Deficiencies cited: 14
Staffing ratios: 17
Staffing ratios: 18
Staffing ratios: 19
Staffing ratios: 20
Staffing ratios: 19
Staffing ratios: 17
Staffing ratios: 16
Staffing ratios: 16
Staffing ratios: 19
Staffing ratios: 20
Staffing ratios: 21
Staffing ratios: 19
Staffing ratios: 19
Staffing ratios: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Named in medication administration deficiency and COVID-19 outbreak response | |
| LPN #3 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| LPN #4 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| LPN #5 | Named as staff exposed to COVID-19 positive resident | |
| CNA #2 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| CNA #3 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| CNA #4 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| CNA #5 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| CNA #6 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| CNA #7 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| Rehab #1 | Named as staff exposed to COVID-19 positive resident and failure to isolate | |
| ICP #1 | Infection Control Preventionist | Named in infection control deficiency and outbreak response |
| ICP #2 | Infection Control Preventionist | Named in infection control deficiency and outbreak response |
| DON | Director of Nursing | Named in medication administration deficiency and infection control oversight |
Inspection Report
Annual Inspection
Census: 156
Capacity: 247
Deficiencies: 12
Apr 26, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations and a review of compliance with federal and state regulations.
Findings
Deficiencies were cited related to the facility's failure to provide a homelike environment during meal service, failure to develop and implement a person-centered baseline care plan within 48 hours of admission, failure to maintain professional standards of nursing practice, insufficient staffing, failure to maintain fire safety and life safety code requirements, medication administration errors, and infection control breaches. The facility was also found not to have proper licensure and failed to notify CMS of a name change.
Complaint Details
Complaint investigation included multiple complaint numbers: NJ00157696, NJ00156541, NJ00156374, NJ00154588, NJ00154495. Some complaints were substantiated related to medication errors, staffing, and care planning.
Severity Breakdown
Level D: 10
Level E: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to provide a homelike environment during meal service as evidenced by meals left on trays with trash while residents were eating. | Level D |
| Facility failed to develop and implement a person-centered baseline care plan within 48 hours of admission for Resident #381. | Level D |
| Facility failed to maintain professional standards of nursing practice for medication administration for Residents #92, #228, and #114. | Level D |
| Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | Level D |
| Facility failed to maintain a safe environment free from accident hazards for Resident #119 related to fall risk and care planning. | Level D |
| Facility failed to maintain fire safety requirements including sprinkler system maintenance, fire door inspections, and fire resistance-rated elements. | Level E |
| Facility failed to maintain HVAC system in accordance with manufacturer specifications and NFPA standards. | Level E |
| Facility failed to maintain electrical systems and generator certification in accordance with NFPA standards. | Level E |
| Facility failed to maintain medication administration error rates below 5%, with an observed error rate of 11.5%. | Level D |
| Facility failed to maintain infection prevention and control program including hand hygiene and use of gloves. | Level D |
| Facility failed to maintain proper pharmacy services including medication storage and documentation. | Level D |
| Facility failed to maintain proper licensure and failed to notify CMS of facility name change. | Level D |
Report Facts
Census: 156
Total Capacity: 247
Deficiencies cited: 13
Medication error rate: 11.5
Staffing ratio: 5.6
Staffing ratio: 8
Staffing ratio: 1
Staffing ratio: 10
Staffing ratio: 9
Staffing ratio: 11
Staffing ratio: 6
Staffing ratio: 7
Staffing ratio: 30
Staffing ratio: 167
Inspection Report
Complaint Investigation
Census: 191
Deficiencies: 1
Apr 4, 2022
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with professional standards of care related to wound management for residents.
Findings
The facility failed to follow acceptable professional standards and their wound care management policy during treatment of one resident, specifically regarding glove use and hand hygiene during wound care, which could potentially affect all residents with wounds.
Complaint Details
The facility was found not in substantial compliance based on a complaint survey. The deficient practice involved Registered Nurse #1 failing to follow professional standards and facility policy during wound care treatment of one resident. RN #1 acknowledged the failure to change gloves and perform hand hygiene appropriately.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow acceptable professional standards and facility wound care policy during wound treatment, including improper glove use and hand hygiene. | SS=D |
Report Facts
Sample size: 3
Census: 191
Deficiency completion date: May 13, 2022
Monitoring period end date: Jul 31, 2022
Number of nurses monitored weekly: 4
Monitoring duration weekly: 4
Monitoring duration monthly: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in deficiency for failing to follow wound care professional standards and policy |
Inspection Report
Annual Inspection
Census: 177
Deficiencies: 1
Apr 22, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
The facility was found not to be in compliance with infection control regulations related to COVID-19 practices. Specifically, a Laboratory Technician failed to follow proper PPE and hand hygiene protocols on the COVID-19 positive unit, risking transmission of infection.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow appropriate infection prevention and control measures on the COVID-19 positive unit, including improper use and removal of PPE and lack of hand hygiene by a Laboratory Technician. | SS=D |
Report Facts
Census: 177
Sample size: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laboratory Technician | Laboratory Technician (LT) | Named in infection control deficiency for improper PPE use and hand hygiene |
| Registered Nurse Unit Manager | RNUM | Interviewed regarding Resident #31 and infection control practices |
| Licensed Practical Nurse | LPN | Observed and interviewed regarding PPE use with Resident #31 |
| Infection Preventionist | IP | Interviewed regarding infection control policy and PPE procedures |
| Administrator | Administrator | Discussed concerns about infection control with surveyor |
| Director of Nursing | DON | Discussed concerns about infection control with surveyor |
Inspection Report
Life Safety
Deficiencies: 0
Apr 22, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and met the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Routine
Census: 168
Deficiencies: 0
Apr 1, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 156
Deficiencies: 0
Dec 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 1
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