Inspection Reports for
Complete Care At Harborage Llc
7600 River Rd, North Bergen, NJ, 07047
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
87% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
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
Routine
Deficiencies: 6
Date: Dec 6, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident care, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents on psychoactive medications, inadequate assistance with activities of daily living such as repositioning and incontinence care, failure to ensure medication administration on dialysis days, presence of expired medical supplies, unsecured medication carts, and incomplete documentation of medication administration.
Deficiencies (6)
Failed to develop care plans related to use and monitoring of psychoactive medications for one resident.
Failed to provide necessary repositioning and incontinence care for two residents dependent on assistance with activities of daily living.
Failed to ensure ongoing communication with dialysis facility and failed to administer medications on dialysis days for one resident.
Medication rooms on three nursing units had expired medical products or items left open.
One medication cart and one rolling cart were left unsecured and unattended, risking medication diversion.
Failed to maintain accurate medical records and documentation of medication administration for two residents.
Report Facts
Residents reviewed for unnecessary medications: 35
Residents reviewed for Activities of Daily Living: 41
Residents reviewed for dialysis: 41
Missed medication administrations for Resident R61: 16
Missed medication administrations for Resident R61: 19
Missed medication administrations for Resident R61: 17
Missed medication administrations for Resident R71: 5
Missed medication administrations for Resident R22: 9
Expired items observed: 10
Expired items observed: 2
Expired items observed: 1
Expired items observed: 1
Expired items observed: 1
Expired items observed: 1
Expired items observed: 12
Expired items observed: 29
Expired items observed: 24
Expired items observed: 1
Expired items observed: 2
Expired items observed: 1
Expired items observed: 1
Expired items observed: 34
Expired items observed: 2
Expired items observed: 10
Expired items observed: 1
Expired items observed: 1
Medication cart unattended duration: 8
Insulin pens left unsecured: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, medication administration, and facility policies |
| LPN1 | Licensed Practical Nurse | Left medication cart unlocked during medication pass |
| LPN8 | Licensed Practical Nurse | Nurse on PM shift who could not recall missed medication administration situation |
| RN1 | Registered Nurse | Interviewed regarding dialysis medication administration and communication |
| RN2 | Registered Nurse | Interviewed regarding dialysis medication administration and communication |
| Unit Manager | Unit Manager | Confirmed insulin pens left unsecured on rolling cart |
| Corporate Nurse | Corporate Nurse | Interviewed regarding medication administration documentation |
| Administrator | Administrator | Interviewed regarding medication cart security |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 6, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, medical record accuracy, and medication administration in a nursing home facility.
Findings
The facility failed to provide adequate repositioning and incontinence care to residents dependent on assistance with activities of daily living, and failed to maintain accurate medical records for medication administration for some residents. Documentation lapses and missed care opportunities were noted, though harm was minimal.
Deficiencies (2)
Failure to provide necessary repositioning and incontinence care to residents dependent on assistance with activities of daily living.
Failure to maintain accurate medical records and documentation of medication administration for residents.
Report Facts
Residents reviewed for ADLs: 9
Total sample of residents: 41
Missed bladder documentation opportunities for Resident 139 in October 2024: 42
Missed bladder documentation opportunities for Resident 139 in November 2024: 23
Missed turning and repositioning documentation opportunities for Resident 139 in October 2024: 42
Missed turning and repositioning documentation opportunities for Resident 139 in November 2024: 23
Missed turning and repositioning documentation opportunities for Resident 139 in December 2024: 3
Missed medication administrations for Resident 71 on 11/14/24 and 11/26/24: 5
Missed medication administrations for Resident 22 on 10/20/24: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed expectations for incontinence care and medication documentation; interviewed regarding findings |
| Licensed Practical Nurse 8 | Licensed Practical Nurse | Interviewed regarding missed medication administration on 11/14/24 |
| Registered Nurse 1 | Registered Nurse | Confirmed importance of repositioning and incontinence care for Resident 139 |
| Registered Nurse 2 | Registered Nurse | Confirmed importance of repositioning and incontinence care for Resident 139 |
| Certified Nurse Aide 2 | Certified Nurse Aide | Interviewed about resident monitoring and care checks |
| Corporate Nurse 1 | Corporate Nurse | Interviewed regarding medication administration documentation issues |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Jan 8, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to administer medication as ordered and failure to implement an effective infection prevention and control program during an active COVID-19 outbreak.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to medication administration errors for Resident #6 and significant failures in infection control practices during a COVID-19 outbreak, including incomplete contact tracing and testing of exposed residents and staff, leading to an Immediate Jeopardy status.
Findings
The facility failed to administer medication as ordered for one resident and did not follow its medication administration policy. Additionally, the facility failed to prevent the spread of COVID-19 by not performing adequate contact tracing, not consistently testing exposed residents and staff according to CDC and local health department guidelines, and not fully implementing its COVID-19 outbreak plan, resulting in an Immediate Jeopardy situation.
Deficiencies (2)
Failure to administer medication as ordered and failure to follow medication administration policy for Resident #6.
Failure to provide and implement an infection prevention and control program during an active COVID-19 outbreak, including failure to perform contact tracing and consistent testing of exposed residents and staff.
Report Facts
Residents tested positive for COVID-19: 55
Staff tested positive for COVID-19: 34
Residents involved in medication deficiency: 1
Residents present during outbreak: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration failure and infection control deficiencies. |
| ICP #1 | Infection Control Preventionist | Initially responsible for infection control and contact tracing; left on 10/3/23. |
| ICP #2 | Infection Control Preventionist | Started 10/28/23; involved in infection control and unable to provide documentation of proper contact tracing and testing. |
| LPN #2 | Licensed Practical Nurse | Documented Resident #6's condition and medication administration. |
| Unit Manager/LPN #1 | Unit Manager / Licensed Practical Nurse | Documented Resident #6's symptoms and orders. |
| Respiratory Therapist | Respiratory Therapist | Worked during outbreak but was not tested for COVID-19 until 1/3/24. |
Inspection Report
Complaint Investigation
Census: 186
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
Failure to implement CDC and CMS infection control guidance to prevent spread of COVID-19, resulting in Immediate Jeopardy.
Failure to provide pharmaceutical services ensuring accurate medication administration and documentation.
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
Routine
Census: 167
Deficiencies: 10
Date: Apr 26, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, medication management, staffing, infection control, and facility operations.
Complaint Details
Complaint # NJ00156374 related to medication administration and respiratory care; Complaint # NJ00154588 related to incontinence care and staffing.
Findings
The facility was found deficient in multiple areas including failure to provide a homelike environment during meal service, failure to develop baseline care plans within 48 hours of admission, failure to maintain professional nursing standards, failure to provide timely incontinence care, failure to maintain fall prevention interventions, failure to provide appropriate respiratory care, insufficient nursing staff to meet resident needs, medication management errors, failure to notify CMS of facility name change, and breaches in infection control practices.
Deficiencies (10)
Failed to provide a homelike environment during meal service by leaving meals on trays and trash in front of residents during meals.
Failed to develop and implement a person-centered baseline care plan within 48 hours of admission for a resident with impaired communication due to language barrier.
Failed to maintain professional nursing standards during medication administration and documentation for multiple residents.
Failed to provide timely incontinence care to a resident dependent on staff for care, resulting in saturated briefs and pads.
Failed to maintain fall prevention interventions by not properly positioning floor mats as ordered for a resident at risk for falls.
Failed to provide safe and appropriate respiratory care including improper storage of nasal cannula and failure to address resident's respiratory distress concerns.
Failed to provide sufficient nursing staff to meet resident needs and maintain mandated staff-to-resident ratios.
Failed to hold blood pressure medication according to physician orders resulting in administration when systolic blood pressure was below hold parameters.
Failed to notify CMS and obtain authorization for a change in facility name, continuing to use an unapproved facility name.
Failed to maintain proper infection control practices during medication administration including failure to wash hands, sanitize equipment, and prevent contamination.
Report Facts
Residents on 2nd floor per CNA assignment: 10
Staff to resident ratio: 5.6
Medication error rate: 11.5
Blood pressure parameters: 100
Staffing deficiencies: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Assigned to Resident #100, discussed incontinence care delays and staffing workload. |
| RN | Registered Nurse | Observed administering medication to Resident #92 without proper vital checks and hand hygiene. |
| LPN | Licensed Practical Nurse | Observed administering medication to Resident #228 without proper vital checks and hand hygiene. |
| RT | Respiratory Therapist | Failed to report resident's respiratory distress and suctioning needs to supervisory staff. |
| Licensed Nursing Home Administrator | Administrator | Interviewed regarding facility name change and staffing concerns. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including staffing, medication errors, and infection control. |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing ratios and CNA assignments. |
Inspection Report
Annual Inspection
Census: 156
Capacity: 247
Deficiencies: 12
Date: 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.
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.
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.
Deficiencies (12)
Facility failed to provide a homelike environment during meal service as evidenced by meals left on trays with trash while residents were eating.
Facility failed to develop and implement a person-centered baseline care plan within 48 hours of admission for Resident #381.
Facility failed to maintain professional standards of nursing practice for medication administration for Residents #92, #228, and #114.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Facility failed to maintain a safe environment free from accident hazards for Resident #119 related to fall risk and care planning.
Facility failed to maintain fire safety requirements including sprinkler system maintenance, fire door inspections, and fire resistance-rated elements.
Facility failed to maintain HVAC system in accordance with manufacturer specifications and NFPA standards.
Facility failed to maintain electrical systems and generator certification in accordance with NFPA standards.
Facility failed to maintain medication administration error rates below 5%, with an observed error rate of 11.5%.
Facility failed to maintain infection prevention and control program including hand hygiene and use of gloves.
Facility failed to maintain proper pharmacy services including medication storage and documentation.
Facility failed to maintain proper licensure and failed to notify CMS of facility name change.
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
Date: 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.
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.
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.
Deficiencies (1)
Failure to follow acceptable professional standards and facility wound care policy during wound treatment, including improper glove use and hand hygiene.
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
Date: 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.
Deficiencies (1)
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.
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
Date: 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: 35
Deficiencies: 1
Date: Apr 22, 2021
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically related to COVID-19 precautions for a COVID-19 positive resident.
Findings
The facility failed to follow appropriate infection control measures on the COVID-19 positive unit, as evidenced by a Laboratory Technician not properly removing contaminated PPE and failing to perform hand hygiene, potentially risking the spread of infection.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program on the COVID-19 positive unit, including improper PPE use and hand hygiene by staff.
Report Facts
Residents reviewed: 35
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager (RNUM) | Interviewed regarding infection control practices and observed during inspection | |
| Laboratory Technician (LT) | Observed failing to properly remove PPE and perform hand hygiene | |
| Licensed Practical Nurse (LPN) | Observed following proper PPE procedures and interviewed | |
| Infection Preventionist (IP) | Interviewed regarding facility policy on PPE and hand hygiene | |
| Administrator and Director of Nursing (DON) | Interviewed regarding the LT's failure to follow PPE and hand hygiene policies |
Inspection Report
Routine
Census: 168
Deficiencies: 0
Date: 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
Date: 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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