Inspection Reports for
Complete Care At Regent Llc
50 Polifly Road, Hackensack, NJ, 07601
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
120% occupied
Based on a February 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 outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health data, 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: 55
Deficiencies: 3
Date: Feb 3, 2025
Visit Reason
The inspection was conducted based on complaints regarding insufficient nursing staff to meet resident needs, including failure to maintain required minimum direct care staff-to-shift ratios and delayed call bell response times.
Complaint Details
Complaint NJ #176546 regarding staffing shortages and delayed call bell response; Complaint #168864 regarding improper use and documentation of Temporary Nurse Aides (TNAs).
Findings
The facility failed to maintain the mandated CNA to resident ratio of 1:8 on the second floor, with only 5 CNAs for 55 residents (ratio 1:11). Residents reported long delays in call bell responses and incontinence care. Additionally, the facility failed to ensure Temporary Nurse Aides (TNAs) were properly enrolled and certified as required, lacked documentation of staff qualifications, and did not have policies regarding TNAs, NAs, or Hospitality Aides.
Deficiencies (3)
Failed to maintain required minimum direct care staff-to-shift ratios as mandated by New Jersey, resulting in insufficient nursing staff.
Failed to answer call bells and provide incontinence care in a timely manner.
Failed to ensure Temporary Nurse Aides (TNAs) were enrolled in school and completed CNA certification as mandated, and lacked documented evidence of staff competency and appropriate policies.
Report Facts
Resident census: 55
Certified Nurse Aides (CNAs) on duty: 5
CNA to resident ratio: 11
Required CNA to resident ratio: 8
Disciplinary action forms: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 / HK #1 | Temporary Nurse Aide / Housekeeper | Worked as TNA during COVID, did not pass CNA written test, assigned residents without documented competency or certification |
| NA #2 | Nurse Aide (no longer employed) | Assigned residents without documented evidence of CNA certification or competency |
| Hospitality Aid / HK #2 | Hospitality Aid / Housekeeper | Worked as TNA during COVID, did not pass CNA written test, assigned residents without documented competency or certification |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding staffing and transition from previous company | |
| Director of Nursing (DON) | Interviewed regarding staffing, staff qualifications, and policy changes | |
| Staffing Coordinator (SC) | Interviewed regarding staffing ratios and use of TNAs | |
| President of Clinical Services (VPoCS) | Interviewed regarding staff training and call bell response | |
| Director of Human Resources | Interviewed regarding employee files and staffing |
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 15
Date: Feb 3, 2025
Visit Reason
Complaint investigation regarding multiple concerns including call bell accessibility, facility cleanliness, staff credential verification, bed hold notifications, MDS coding accuracy, care planning, medication administration, respiratory care, staffing levels, food safety, medical record completeness, and call bell system functionality.
Complaint Details
Complaint #176546 and #168864 regarding staffing shortages, call bell response delays, use of Temporary Nurse Aides without proper certification, and other care and safety concerns.
Findings
The facility was found deficient in multiple areas including failure to ensure call bell accessibility, maintain a clean environment, verify licensed staff credentials prior to hire, provide written bed hold notifications, accurately code MDS assessments, develop comprehensive care plans, administer medications per manufacturer instructions, provide appropriate respiratory care, maintain adequate staffing ratios, ensure food safety and sanitation, maintain complete medical records, and ensure call bell system functionality.
Deficiencies (15)
Resident's call light was not readily accessible within reach, posing risk for unmet needs.
Facility failed to maintain a safe, clean, and homelike environment due to accumulation of dust on vents and broken tissue paper holder.
Licensed staff credentials were not verified prior to hire for 5 of 8 newly hired licensed staff.
Facility failed to provide written bed hold notifications for 4 of 5 residents reviewed for hospitalizations.
Facility failed to accurately code MDS assessments for 3 residents, including miscoding of oxygen use, wounds, and discharge dates.
Facility failed to develop and implement comprehensive care plans reflecting residents' preferences and medical needs for 2 residents.
Facility failed to adhere to professional standards by not ensuring accurate psychiatric diagnoses and improper medication administration (crushing delayed release tablets).
Facility failed to ensure ordered laboratory tests, daily weights, and CHF assessments were completed and documented as ordered for a resident.
Facility failed to maintain proper care and documentation for residents receiving enteral feedings, including unclear and duplicate orders.
Facility failed to ensure proper care and storage of respiratory equipment including BIPAP masks and oxygen tubing.
Facility failed to provide sufficient nursing staff to meet resident needs and maintain mandated CNA to resident ratios; call bells were not answered timely.
Facility failed to ensure Temporary Nurse Aides were enrolled and progressing in CNA training as required and lacked policies for non-certified staff assignments.
Facility failed to maintain sanitation and infection control in dietary services including expired food, improper hair restraints, improper glove use, and refrigerator temperature control.
Facility failed to maintain complete, accurate, and accessible medical records including missing transfer forms and inconsistent documentation.
Call bell annunciator panel was unplugged, preventing audible and visual notification of call bell activation at nurse's station.
Report Facts
Resident census: 161
CNA to resident ratio: 1
Number of licensed staff with unverified credentials: 5
Residents missing written bed hold notification: 4
Residents with MDS miscoding: 3
Residents with deficient care plans: 2
Residents with respiratory care deficiencies: 3
Days with inaccurate posted staffing report: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1/HK #1 | Temporary Nurse Aide / Housekeeper | Worked as TNA without documented enrollment or competency; reassigned as housekeeper |
| NA #2 | Temporary Nurse Aide | Worked as TNA without documented enrollment or competency; no employee file found |
| Hospitality Aide / HK #2 | Housekeeper | Worked as TNA without documented enrollment or competency; reassigned as housekeeper |
| RN/MDSS | Registered Nurse / MDS Supervisor | Interviewed regarding MDS miscoding and accuracy |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including staffing, medical records, and care concerns |
| VPoCS | Vice President of Clinical Services | Interviewed regarding multiple deficiencies and facility responses |
| LPN #1 | Licensed Practical Nurse | Observed medication administration and interviewed regarding nutrition refrigerator |
| RN #1 | Registered Nurse | Interviewed regarding respiratory care and BIPAP mask |
| RN #2 | Registered Nurse | Interviewed regarding tracheostomy care |
| SC | Staffing Coordinator | Interviewed regarding staffing and posting of staffing reports |
| FSD | Food Service Director | Interviewed regarding dietary sanitation and food safety |
| DM | Director of Maintenance | Interviewed regarding call bell annunciator panel |
Inspection Report
Complaint Investigation
Census: 157
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
The inspection was conducted based on complaint #NJ00170087 to investigate staffing ratio compliance at Complete Care at Regent LLC.
Complaint Details
Complaint #NJ00170087 was substantiated as the facility failed to meet minimum CNA staffing ratios on 27 of 28 day shifts reviewed. No residents were directly affected, but all had the potential to be affected.
Findings
The facility failed to meet the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 27 of 28 day shifts reviewed, indicating a deficiency in staffing levels as mandated by New Jersey state law.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 27 of 28 day shifts.
Report Facts
Census: 157
Days deficient in CNA staffing: 27
Required CNA staffing: 19
Actual CNA staffing: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided in-service training to Staffing Coordinator regarding appropriate staffing levels | |
| Staffing Manager/Human Resources | Scheduled additional staff to meet minimum staffing ratios | |
| Scheduling Manager or designee | Conducts weekly and monthly audits to ensure staffing compliance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 4, 2023
Visit Reason
The inspection was conducted based on a complaint alleging the facility failed to follow a physician's order to remove a midline catheter prior to discharging Resident #1 and failed to coordinate discharge planning properly.
Complaint Details
Complaint #NJ00167634 involved failure to remove a midline catheter prior to discharge and inadequate discharge planning for Resident #1. The complaint was substantiated based on medical record review and staff interviews.
Findings
The facility did not discontinue Resident #1's midline catheter prior to discharge as ordered, and discharge planning was inadequate, resulting in the resident arriving at a shelter with the catheter still in place. Interviews with nursing staff and social services confirmed these failures.
Deficiencies (2)
Failure to follow physician's order to remove midline catheter prior to discharge.
Failure to coordinate discharge planning properly, resulting in resident discharged to shelter with midline catheter in place.
Report Facts
Residents reviewed for discharge: 4
Date of physician order to discontinue midline catheter: Aug 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Helped with Resident #1's discharge but did not perform skin assessment or remove midline catheter |
| RN #2 | Registered Nurse | Resident #1's primary nurse at discharge; did not return surveyor's call |
| Regional Nurse/Acting Director of Nursing | Acting Director of Nursing | Confirmed midline catheter was not discontinued prior to discharge and emphasized importance of removal |
| Licensed Nursing Home Administrator | LNHA | Stated expectation that Director of Social Services confirm bed availability at shelter |
| Director of Social Services | DSS | Failed to confirm bed availability at shelter and relied on family information |
| Social Worker | Social Worker | Communicated with family and facility staff regarding discharge planning |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 2, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with federal regulations regarding accurate completion and timely transmission of Minimum Data Set (MDS) assessments, proper coding of assessments, medication administration, restorative nursing services, and medication storage and labeling.
Findings
The facility was found deficient in timely and accurate transmission of MDS assessments for multiple residents, inaccurate MDS coding, failure to administer medications per physician orders, failure to label enteral feeding equipment properly, lack of restorative nursing services and hand splint use for a resident with contracture, and failure to secure controlled medications and remove expired or discontinued medications from medication carts.
Deficiencies (6)
Failed to accurately complete and timely transmit the Minimum Data Set (MDS) for 5 of 46 residents reviewed.
Failed to ensure each resident receives an accurate assessment, including language preference and active diagnoses coding errors for 7 of 29 residents.
Failed to follow acceptable standards of clinical practice regarding medication administration for Resident #135, including failure to administer Midodrine HCL when blood pressure was less than 100.
Failed to label enteral feeding bottle and water flush bag with required information for Resident #18.
Failed to accurately assess and implement interventions for a resident with contracture and limited range of motion, including lack of restorative nursing services and hand splint use for Resident #48.
Failed to secure controlled medications and ensure expired and discontinued medications were removed timely from medication carts on multiple floors.
Report Facts
Residents with untimely MDS transmission: 5
Residents with inaccurate MDS coding: 7
Residents reviewed for medication administration: 5
Residents reviewed for tube feeding labeling: 3
Residents reviewed for restorative nursing: 1
Controlled medication bottles found unsecured: 2
Expired medications found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/MDS Coordinator | Interviewed regarding MDS transmission delays and coding errors | |
| Regional Registered Nurse / Acting Director of Nursing (DON) | Acknowledged MDS transmission delays and coding errors | |
| Licensed Practical Nurse (LPN #1) | Provided care and confirmed medication administration and labeling issues | |
| Licensed Practical Nurse (LPN #2) | Interviewed about medication administration and tube feeding labeling | |
| Licensed Nursing Home Administrator (LNHA) | Discussed concerns regarding MDS, medication, restorative nursing, and labeling issues | |
| Certified Nurse Aide (CNA) | Interviewed about restorative nursing services | |
| Rehab Director and Rehab Supervisor | Provided documentation and discussed restorative nursing recommendations | |
| Consultant Pharmacist | Discussed medication cart inspection findings | |
| Acting Director of Nursing (DON) | Provided OT notes and discussed medication cart responsibilities |
Inspection Report
Annual Inspection
Census: 147
Capacity: 180
Deficiencies: 9
Date: Oct 2, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to timely and accurate completion and transmission of Minimum Data Set (MDS) assessments, accuracy of MDS coding, failure to follow professional standards in medication administration and labeling, failure to maintain proper staffing ratios, and life safety code violations including fire safety system deficiencies.
Deficiencies (9)
Facility failed to accurately complete and timely transmit Minimum Data Set (MDS) for 5 of 46 residents reviewed.
Facility failed to accurately code the Minimum Data Set (MDS) for 7 of 29 residents reviewed for accuracy.
Facility failed to follow acceptable standards of clinical practice with regards to labeling and dating enteral feedings and following physician's orders for medication parameters.
Facility failed to secure stored controlled medications and ensure expired and discontinued medications were removed timely from medication carts.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Doors in hazardous areas were held open by door wedges instead of automatic release devices.
Fire alarm system lacked automatic smoke detection at the fire alarm control unit location.
Fire alarm system and components were not tested and maintained in accordance with NFPA requirements; missing semi-annual inspections and smoke detector sensitivity tests.
Sprinkler system was not inspected on a quarterly basis as required.
Report Facts
Residents reviewed for MDS transmission: 46
Residents reviewed for MDS coding accuracy: 29
Current census: 147
Total licensed capacity: 180
Deficient CNA staffing days: 14
Required CNA staffing: 18
Actual CNA staffing: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed resident communication needs and medication administration |
| LPN #2 | Licensed Practical Nurse | Acknowledged failure to label enteral feeding water and flush bags |
| DON | Director of Nursing | Educated MDS coordinator, acknowledged late MDS transmissions, discussed staffing and medication concerns |
| MDS Coordinator | Registered Nurse | Responsible for MDS completion and coding, acknowledged errors and late transmissions |
| LNHA | Licensed Nursing Home Administrator | Informed of staffing deficiencies and MDS concerns |
| Maintenance Director | Maintenance Director | Confirmed door wedge use and fire alarm system deficiencies |
| Consultant Pharmacist | Consultant Pharmacist | Could not explain why expired medications were not removed during inspections |
| Restorative Nursing Aide | Restorative Nursing Aide | Responsible for restorative nursing exercises, acknowledged lack of care for Resident #48 |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 14, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to respiratory care and medication administration in the nursing facility.
Findings
The facility failed to follow a Physician's Order for oxygen use for one resident, resulting in inappropriate oxygen flow rates and inconsistent use. Additionally, medication administration errors were observed, including incorrect timing and technique for insulin and oral diabetes medications, resulting in a medication error rate of 12.12%.
Deficiencies (2)
Failure to follow Physician's Order for oxygen use, including incorrect oxygen flow rate and inconsistent oxygen use by Resident #67.
Medication administration errors resulting in a 12.12% error rate during observed medication passes, including insulin administration timing and technique errors for Residents #47 and #57.
Report Facts
Medication administration opportunities: 33
Medication administration errors: 4
Medication error rate: 12.12
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding oxygen use and medication administration policies |
| Assistant Director of Nursing | Assistant Director of Nursing/Staff Development (ADON/SD) | Interviewed regarding staff education and medication administration observations |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Observed administering medications and interviewed about medication administration practices |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Interviewed regarding medication administration and in-services |
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 6
Date: Jun 14, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to respiratory/tracheostomy care and suctioning, medication administration errors, emergency lighting, fire alarm system installation, HVAC maintenance, and essential electrical system maintenance and testing.
Deficiencies (6)
Facility failed to follow a Physician's Order for oxygen use for one resident.
Medication administration error rate exceeded 5%, with errors observed in medication passes to residents.
Facility failed to provide battery backup emergency lighting for the generator's transfer switch.
Facility failed to provide audible and visible fire alarm notification signals in an outside fenced courtyard.
Facility failed to maintain ventilation systems properly; two resident bathroom exhaust fans and one rooftop exhaust fan were not functioning.
Facility failed to provide a remote manual stop station for the emergency generator.
Report Facts
Census: 136
Medication administration error rate: 12.12
Number of residents reviewed for respiratory care: 2
Number of residents with medication errors: 2
Number of medication opportunities observed: 33
Number of medication errors observed: 4
Number of residents with deficient oxygen care: 1
Number of exhaust fans not working: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to education and audits for medication administration and respiratory care deficiencies |
| Assistant Director of Nursing/Staff Development | ADON/SD | Responsible for education of staff and medication pass observations |
| Certified Nursing Assistant | CNA | Observed during medication administration and respiratory care |
| Licensed Practical Nurse | LPN | Observed administering medications and respiratory care |
| Consultant Pharmacist | CP | Provided medication pass observations and in-services |
| Maintenance Director | Maintenance Director | Interviewed and involved in correction of emergency lighting, fire alarm, HVAC, and generator deficiencies |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 0
Date: Jul 9, 2021
Visit Reason
The inspection was conducted as a complaint survey related to complaint numbers NJ144813, NJ139992, and NJ142480.
Complaint Details
Complaint numbers NJ144813, NJ139992, and NJ142480 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities on this complaint survey.
Report Facts
Sample size: 5
Inspection Report
Abbreviated Survey
Census: 132
Deficiencies: 1
Date: Mar 12, 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 not to be in compliance with infection control regulations, specifically failing to ensure proper sanitization and disinfection of equipment used by visiting providers, which posed a risk for infection spread among residents.
Deficiencies (1)
Failure to follow infection control regulations for proper equipment sanitization and disinfection of instruments used to examine residents' eyes.
Report Facts
Sample size: 11
Deficiency correction completion date: Jun 9, 2021
Follow-up revisit date: Jul 16, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Discussed infection control issues with surveyor | |
| Administrator | Discussed infection control issues with surveyor |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
The inspection was conducted as a complaint survey identified by Complaint #: NJ00135037.
Complaint Details
Complaint #: NJ00135037; the facility was found compliant based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 127
Deficiencies: 0
Date: Nov 25, 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 recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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