Home / New Jersey / North Bergen
7600 River Rd, North Bergen, NJ 07047 · Hudson County · (201) 854-5400
247 certified beds, about 227 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1991
CMS Care Compare ratings, data as of September 1, 2026 · CCN 315307 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 1, 2026, inspectors cited 25 health deficiencies (the New Jersey average is 8.6, the national average 9.2).
Of 47 health citations since April 2023, 2 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 1 fine totaling $27,378 in the last three years; the largest was $27,378, and the latest is dated May 1, 2026.
Nurses and nurse aides worked 3.48 hours per resident per day, against 3.85 across New Jersey and 3.86 nationally. Registered nurses accounted for 0.77 of those hours.
40.2% of nursing staff left within the year CMS measured (New Jersey average 39.7%).
CMS links it to Complete Care, an affiliated group of 85 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 47 health citations on file.
Inspectors wroteBased on observations, interviews, review of medical records, and review of pertinent facility documents on 5/18/26, it was determined that the facility failed to ensure that a cognitively impaired resident who had a tracheostomy and was ventilator dependent was free from physical abuse. On 5/10/26, the police notified the facility of an allegation of abuse by a Respiratory Therapist (RT). The Licensed Nursing Home Administrator (LNHA) was shown a video by the police that was taken by a hidden video camera that was placed in the resident's room by their family member. The RT was suspended immediately and did not return to the facility. The facility self-corrected and put themselves back in compliance to prevent serious harm from occurring or recurring on 5/11/26 when facility staff were educated on facility abuse policies. The IJ was Past Non-Compliance (PNC). [...]
Inspectors wroteBased on interviews, record review, and review of pertinent facility documentations on 5/18/26, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) potential abuse related to multiple incidents of resident injuries of unknown origin dated 3/21/26 and 4/16/26 for Resident #1 and dated 4/15/26 for Resident #3. This deficient practice was identified for 2 of 4 residents reviewed for abuse and neglect, Resident #1 and Resident #3. The deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #1. [...]
Inspectors wroteBased on interviews, record review, and review of pertinent facility documentations on 5/18/26, it was determined that the facility failed to ensure complete and thorough investigations to rule out abuse were done for multiple incidents of resident injury dated 3/21/26 and 4/16/26 for Resident #1 and an incident dated 4/15/26 for Resident #3. This deficient practice was identified for 2 of 4 residents reviewed for abuse and neglect, Resident #1 and Resident #3. The deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #1. [...]
Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire; a.) by not completing a prior to hiring employees for 37 of 112 employees, b.) not documenting verification of the licenses of 5 of 52 nurses hired since 12/6/24, and c.) not documenting verification of the certification of 3 of 45 Certified Nursing Assistants (CNAs), in accordance with facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy. The deficient practice was evidenced by the following: On 4/28/26, 4/29/26, and 4/30/26, Surveyor #1 reviewed the Human Resource Records (HRR) including the Criminal Background Investigations (CBI) for 87 employees hired since last recertification survey, 12/6/24. The following concerns were revealed: [...]
Inspectors wroteBased on interviews of facility staff and a review of facility provided documentation, it was determined that the facility failed to ensure the nursing staff possessed and maintained the appropriate competencies and skills to provide nursing care to the facilities residents for 5 of 5 nursing employees reviewed. The deficient practice was evidenced by the following: On 4/29/26 at 12:30 PM, the surveyor requested documentation of nursing competencies and annual performance evaluations for five nurses selected from the facility provided active employee roster. On 5/1/26 at 9:45 AM, the Assistant Director of Nursing (ADON) provided 94 Inservice sign in sheets conducted since 1/1/25. The in-service sheets reflected a topic, 0 of 94 sheets reflected nursing competencies performed, a syllabus of information or skills presented, skill assessments or minutes from the in-service. [...]
Inspectors wroteBased on interviews of facility staff and a review of facility provided documentation, it was determined that the facility failed to ensure the Certified Nursing Assistants employed by the facility received an annual evaluation of their work performance facilities residents for 4 of 5 employees reviewed. The deficient practice was evidenced by the following: On 4/29/26 at 12:30 PM, the surveyor requested from the Director of Nursing (DON) the annual performance evaluations for five Certified Nursing Assistants (CNA) selected from a roster of active employees provided by facility. On 5/1/26 at 10:45AM, the DON confirmed the performance evaluations for 4 of the 5 selected employees did not have written annual evaluations: Employee #1 (E1), CNA hired on 2/24/14. No performance evaluation on file. E #2, CNA hired on 1/11/23. No performance evaluation on file. E #3, CNA hired on 12/17/24. [...]
Inspectors wroteComplaint #2643214 Based on observation, interview, and record review, it was determined that the facility failed to ensure consistent a.) accountability, b.) disposition (destruction) of the controlled dangerous substance (narcotic; medications, with high potential for abuse, were tracked with detail) for 2 of 8 medication carts inspected, and c.) properly dispose of non-narcotic medications, identified during the medication pass observation of 4 nurses who administered medications to 5 residents. The deficient practice was evidenced by the following: 1. On [DATE] at 11:53 AM, in the presence of Registered Nurse #1 (RN #1), Surveyor #1 (S #1) began the narcotic medication (med) inspection, which was stored in a mounted, double locked portion of the med cart (narcotic box) located on the South side of the fourth floor. [...]
Inspectors wroteComplaint #2738075Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 4/29/26, the surveyors observed 4 nurses administer medications to 5 residents. There were 30 opportunities, and 4 errors were observed which resulted in a medication error rate of 13.33%. This deficient practice was identified for 2 of 5 residents (Resident #141 and #257), that was administered by 2 of 4 nurses. This deficient practice was evidenced by the following: 1. On 4/29/26 at 8:05 AM, two surveyors observed Registered Nurse #1 (RN #1) prepare medications (meds) for Resident #141. The meds included the following physician's order (PO): [...]
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to; a.) properly label an opened blood glucose test strips, b) identify and dispose of expired biological supply, and c) properly store insulin pens, in accordance with currently accepted professional principles and facility's policy. This deficient practice was identified for 4 of 8 medication carts and 1 of 2 medication rooms inspected and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
Inspectors wroteBased on interviews of facility staff and review of facility provided documentation, it was determined the facility failed to ensure and document that all Certified Nursing Assistants (CNAs) completed 12 hours of in-service training including the topics of preventing resident abuse, dementia management, and areas of weakness identified in the individual CNA's annual review for 4 of 5 CNA employees reviewed. The deficient practice was evidenced by the following: The surveyor reviewed the training records provided by the facility for five selected CNAs and revealed: -A review of the facility provided 94 attendance sheets for in-services provided to all staff members since 1/1/25, 0 of 94 attendance sheets provided included a number of credited hours or minutes assigned to the given topic. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the urinary catheter bag was covered. This deficient practice was identified for 1 of 3 residents who had urinary catheters (Resident #122), and was evidenced by the following:On 4/27/26 at 8:42 AM, the surveyor observed that Resident #122 had a urinary catheter bag that was uncovered. On 4/27/26 at 9:30 AM, the surveyor reviewed the electronic medical record of Resident #122. The admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included, but were not limited to, other neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by damage to the nerves that control bladder function). [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 2 of 32 residents (Resident #122 and Resident #221) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 4/27/26 at 8:42 AM, the surveyor observed Resident #122 lying in bed, the resident's call device was wrapped around itself and dangled over the outlet on the wall, and out of reach of the resident. On 4/28/26 at 11:27 AM, the surveyor made a second observation of Resident #122 lying in bed. The call device was in the same position as the previous observation, out of reach of the resident. [...]
Inspectors wroteCOMPLAINT NJ #2669783 and #2735273 Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure the resident representative was notified of a significant change in condition, including a fall for 1 of 2 residents (Resident #252) and a resident's death for 1 of 1 resident (Resident #250), and failed to ensure such notification was documented in the medical record for 2 of 2 residents (Resident #250 and Resident #252) reviewed for notification of change. This deficient practice was evidenced by the following: 1. On [DATE] at 11:53 AM, Surveyor #1 (S #1) reviewed the closed records of Resident #250. A review of the admission Record (AR) or face sheet (an admission summary), revealed the resident had diagnoses which included, but were not limited to; [...]
Inspectors wroteNJ#2643214Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 1 of 32 sampled residents (Resident #221) and 1 of 6 residents (Unsampled Resident) from resident council meeting reviewed. This deficient practice was evidenced by the following: 1. On 4/27/26 at 8:35 AM, Surveyor #1 (S #1) observed Resident #221 lying in bed, the floor mat on the right side of the resident was dirty, stained, and had wet pools on it in multiple places. On 4/27/26 at 10:31 AM, S #1 made a second observation of the floor mat which was still stained and had wet pools on it in multiple places. [...]
Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure grievances were documented on the facility grievance form and responses were documented according to facility policy. This deficient practice was identified for 1 of 38 residents (Resident #9) reviewed. This deficient practice was evidenced by the following: On 4/27/26 at 9:16 AM, the surveyor observed Resident #9 who was seated up in bed and stated that they had been in the facility for two years. [...]
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 2 of 38 residents, (Resident #14 and Resident #229), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Resident Assessment (RAI) Manual, dated October 2025, RAI-required Assessment Summary:-The admission (Comprehensive) assessment, the MDS completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) (Care Area Assessment) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). [...]
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 3 of 38 residents (Residents #10, #14, and #85) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 4/27/26 at 10:00 AM, Surveyor #1 (S #1) observed Resident #10 awake, sitting in the wheelchair (w/c), alert and oriented, able to verbalize needs to staff. On 4/28/26 at 10:07 AM, S #1 reviewed the electronic medical record (eMR) of Resident #10, which revealed the following: [...]
Inspectors wroteREPEAT DEFICIENCYBased on observations, interviews, and review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' goals, medical, and psychosocial needs. This deficient practice was identified for 3 of 38 residents (Residents #5, #14, and #85) reviewed for care plan. This deficient practice was evidenced by the following: 1. On 4/28/26 at 11:46 AM, Surveyor #1 (S #1) observed Resident #5 lying in bed awake and able to answer S #1's inquiry. On 4/28/26 at 1:09 PM, S #1 reviewed the electronic medical record (eMR) of Resident #5, which revealed the following: [...]
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure services provided met professional standards of practice by failing to follow the physicians orders for 3 of 38 residents (Residents #9, # 35, and #213) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]
Inspectors wroteComplaint #260384Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to; a.) ensure a timely initial nursing assessment was completed, b.) ensure physician ordered medication was administered, and c.) ensure hospice services were documented, communicated, and coordinated in accordance with the resident's plan of care and standards of clinical practice. This deficient practice was identified for 2 of 2 residents (Resident #11 and Resident #249) reviewed for quality of care, and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
Inspectors wroteBased on observation, interview, record review, and review of pertinent documents it was determined that the facility failed to, a.) follow the physician order and ensure assistive device was consistently applied for 1 of 2 residents (Residents #14) and b.) a physician order was obtained with regard to use of an assistive device for 1 of 2 residents (Resident #253), in accordance with facility policy and standard of practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
Inspectors wroteBased on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to: a.) to ensure fall interventions were consistently implemented for residents identified as being high risk for falls who sustained injuries from fall and b.) ensure a resident with severe cognitive impairment, who was at risk for elopement and had a known history of wandering was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #14) and for 1 of 1 resident reviewed for elopement (Resident #209), in accordance with standards of clinical practice and facility's policies and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide appropriate treatment and services for a resident receiving enteral feeding. This deficient practice was identified for 1 of 3 residents (Residents #73), reviewed for enteral (tube) feeding. This deficient practice was evidenced by the following: On 4/29/26 at 9:34 AM, the surveyor reviewed the electronic medical record (eMR) of Resident #73. A review of the admission Record or face sheet (an admission summary) documented the resident had diagnoses that included but were not limited to, Alzheimer's disease and unspecified severe protein-calorie malnutrition. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/3/26, reflected that resident was rarely/never understood. [...]
Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that residents received the necessary respiratory care and services, according to the standard of clinical practice, specifically that respiratory equipment were labeled and stored in accordance with infection control measures and cautionary signage for oxygen services for 2 of 7 residents reviewed for respiratory care (Resident #227 and #234). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 1 of 5 days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors. This deficient practice was evidenced by the following: On 4/27/26 at 6:18 AM, upon entry into the facility, the surveyor observed a posted Nursing Home Staffing Report (NHSR) in the reception area of the lobby, dated 4/25/26 Day Shift, 7:00 AM-3:00 PM (7-3 shift), Evening Shift 3:00 PM-11:00 PM (3-11 shift), and Night Shift 11:00 PM-7:00 AM (11-7 shift). The NHSR reflected current census (total number of residents) of 230 for all shifts. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified an irregularity during the drug regimen review (DRR) of a resident with chronic kidney disease. The deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #7) and was evidenced by the following:Reference:According to the manufacturer's boxed warnings (the highest safety- related warnings that medication can have, assigned by the Food and Drug Administration.) for Epogen (epoetin alfa): In controlled trials, patients with chronic kidney disease (CKD) experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11grams /deciliter (g/dl). [...]
Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to dispose of garbage and refuse properly in a manner to maintain a sanitary environment and prevent potential pests. This deficient practice was evidenced by the following: On 4/27/26 at 10:02 AM, a tour of the refuse area revealed, one covered compactor with six used gloves around the perimeter, a used mask, debris, and garbage on the front of the compactor on the ground. The surveyor asked who was responsible for keeping the area clean and the Director of Plant Operations (DPO) stated that the hospital housekeeping staff were responsible for cleaning the area, once a week. The DPO confirmed the refuse area should not have garbage and gloves around the perimeter. [...]
Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene practices for 5 of 11 staff (3 Certified Nursing Aides and 2 Kitchen Leadership Staff), during incontinence tour and kitchen tour, and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed. Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: [...]
Inspectors wroteBased on observations and interview, the facility failed to ensure medication rooms on three (2nd nursing unit (NU), 3rd NU, and 5th NU) of four nursing units, did not have expired medical products or items left open. This has the potential to increase of risk of infections due to expiration.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to develop care plans related to use and monitoring of psychoactive medications for one (Resident (R) 49 of five residents reviewed for unnecessary medications out of a sample of 35 residents.
Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to provide two residents (Resident (R) 139 and R108) out of nine residents reviewed for Activities of Daily Living (ADLs) the necessary repositioning and incontinence care to ensure residents dependent on assistance with ADLs received care and services for toileting hygiene and skin protection out of a total sample of 41 residents.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility and failed to ensure a medication was administered on dialysis days for one of one residents (Resident (R) 61) reviewed for dialysis out of a sample of 41.
Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure that one of 10 medication carts (fifth floor south) and one of one rolling cart (fifth floor) were not left unsecured and unmonitored when medication cart was unlocked. This the potential for medication diversion and for residents to obtain medications that could affect their health.
Inspectors wroteBased on interviews, record review and policy review, the facility failed to maintain an accurate medical record for two (Resident (R) 71 and R22) of six residents reviewed for nursing services. The facility failed to ensure medications administrations were accurately documented administration record.
Inspectors wroteBased on interview, record review, and review of pertinent documentation on 01/03/24, 01/05/24, and 01/08/24, it was determined that the facility was in an active COVID-19 outbreak status on 10/2/23, failed to prevent the spread of COVID-19, a highly contagious virus for the following: a.) failing to perform contact trace (CT) of the employees and residents who were exposed to COVID-19 virus, b.) failing to consistently test exposed residents and employees. c.) failing to ensure that the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance were implemented to limit the spread of the infectious disease, and to put into effect the facility's policy titled Emergent Infectious Disease (COVID-19) Outbreak Plan V11 to prevent the spread of Covid-19 which is a highly contagious virus. Reference: [...]
Inspectors wroteBased on interviews and record review, as well as review of pertinent facility documents on 1/3/24, 1/5/24, and 1/8/24 it was determined that the facility failed to administer medication as ordered and to follow the facility's policy titled Administering Medication for 1 of 8 residents (Resident #6), reviewed for medication administration. This deficient practice was evidenced by the following: According to the admission RECORD, Resident #6 was admitted to the facility with diagnoses that included but were not limited to: Cerebral Infarction, Hypertension, and Peripheral Vascular Disease. According to the resident's Minimum Data Set (MDS), an assessment tool dated 12/18/23, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating that the resident cognitive was moderately impaired. [...]
Inspectors wroteBased on observation and interview it was determined that the facility failed to provide a homelike environment during meal service as evidenced by the following. The deficient practice was observed on 2 out of 3 facility floors during lunch service observation. This deficient practice was evidenced by the following: 1. On 4/10/23 at 1:00 PM, during the lunch meal service located on the 2nd Floor dining room (DR), the surveyor observed that all meals in the DR were served and remained on meals trays. The surveyor also observed the Certified Nursing Assistants (CNA's) who were providing assistance with set-up to the residents in the DR left the lid from the food plate on the table and placed all the empty milk and juice containers along with straw papers and other trash in front of the resident. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a person-centered baseline care plan (CP) for a resident within 48 hours of admission. This deficient practice was identified for 1 of 2 residents reviewed, (Resident #381) who had impaired communication related to language barrier. This deficient practice was evidenced as follows: On 4/10/23 at 12:43 PM, during the initial tour, the surveyor observed Resident #381 sitting in a wheelchair in their room. The surveyor greeted the resident who responded in Spanish. On 4/17/23 at 12:20 PM, the surveyor observed Resident #381 sitting in their wheelchair in their room. The surveyor greeted the resident who responded in Spanish. At around the same date and time, the surveyor interviewed the Licensed Practice Nurse (LPN) assigned to the resident. [...]
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain professional standards of nursing practice for 3 of 31 sampled residents observed, Resident #92, #228 and #114 . This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. [...]
Inspectors wroteComplaint # NJ00154588 Based on observations, interviews, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to ensure that timely incontinence care was provided to 1 of 3 residents dependent on staff for care. This deficient practice was observed during a care tour and involved Resident #100. This deficient practice was evidenced by the following: On 4/19/23 at 11:46 AM, the surveyor conducted a care tour with the 2nd floor Licensed Practical Nurse/Unit Manager (LPN/UM). Resident #100 was checked for incontinent care by the 2nd floor LPN/UM. The surveyor observed Resident #100, who was lying in bed, wearing a disposable incontinent brief which appeared to be saturated with urine. There was an absorbent cloth pad underneath Resident #100 which had a yellowish stain on it. [...]
Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow and maintain fall prevention interventions documented on the resident's care plan (CP) for 1 of 2 residents reviewed for falls, Resident #119. The deficient practice was evidenced by the following: On 4/10/2023 at 12:21 PM, the surveyor observed the resident in bed with eyes closed with the right-side floor mat off the floor and leaning against the bed rail. On 4/11/2023 at 12:22 PM, the surveyor observed the resident in bed with eyes closed with the right-side floor mat off the floor and once again leaning against the bed rail. [...]
Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to: a) maintain respiratory care and services for a resident who was receiving an oxygen treatment according to the standards of practice. The deficient practice was identified for 2 of 4 residents, Resident #382 and #114 reviewed for respiratory care. This deficient practice was evidenced by the following: a) On 4/10/23 at 12:56 PM, during the initial tour, the surveyor observed Resident #382 sitting in their wheelchair with oxygen (O2) in use via nasal cannula (n/c) set at 3 liters per minute (3 L/min) attached to a humidified O2 concentrator (a medical device used for delivering O2). The O2 tubing was dated 4/6/23. On 4/18/23 at 11:58 AM, the surveyor observed Resident #382 not in their room. [...]
Inspectors wroteComplaint # NJ00154588 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) provide incontinence care in a timely manner, b.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. [...]
Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to hold a medication used to treat high blood pressure in accordance with physician orders. This deficient practice was identified for 2 of 34 residents reviewed for medication management (Resident #124, Resident #92). The evidence was as follows: 1.) On 4/10/23 at 10:35 AM, the surveyor observed Resident #124 in the room with eyes closed. The resident was non-interviewable. The surveyor reviewed Resident #124's medical record. The resident was admitted to the facility on [DATE] with diagnoses that included but not limited to Hypertension and Anoxic Brain Damage. A review of the electronic Physician Orders for April 2023 reflected a physician order (PO) with a start date of 3/2/23 for a medication, Metoprolol Tartrate. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain a medication rate error below 5%. The surveyor observed 2 nurses administer 26 doses of medication to 3 residents and there were 3 errors which resulted in a medication error rate of 11.50 %. The deficient practice was evidenced by the following: 1. On 4/18/23 at 8:45 AM, during the medication administration observation (med pass), the Surveyor observed the 5TH Floor Registered Nurse (RN) preparing crushed medications for administration to a gastric tube (gtube) resident, Resident #92. The RN opened a packet prepared by the pharmacy, marked for 9:00 AM administration that included 2 medications, Metoprolol Tartrate 25 mg to be administered every 12 hours Hold if Systolic Blood Pressure (SBP) is less than (<) 100 and Famotidine 20 mg twice daily. [...]
Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices to mitigate the spread of infection for 3 of 36 Residents observed, Resident #92, #39, and #228. The deficient practice was observed on 2 out of 4 facility floors during medication administration observation. This deficient practice was evidenced by the following: 1. On 4/18/23 at 8:45 AM, the Surveyor observed medication administration (med pass) on the 5th floor, Vent Unit performed by a Registered Nurse (RN). The State Surveyor observed the RN prepare the crushed medication for a gastric tube (gtube), ventilator dependent Resident, Resident #92 without washing her hands. The surveyor requested that the RN check Resident #92's vitals due to the physician parameter order. [...]
15 fire safety citations on file: 7 on May 1, 2026, 1 on December 6, 2024, 7 on April 26, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| May 1, 2026 | Fine | $27,378 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | New Jersey | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.48 | 3.85 | 3.86 |
| Registered nurses | 0.77 | 0.68 | 0.69 |
| All nursing staff on weekends | 3.06 | 3.50 | 3.42 |
| Nurse aides | 2.17 | ||
| Licensed practical nurses | 0.53 | ||
| Nursing staff turnover (share who left in a year) | 40.2% | 39.7% | 45.8% |
| Registered nurse turnover | 33.3% | 37.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.14 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.64 on weekdays and 3.06 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.68 in April to June 2025 to 3.48 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.48 | 0.77 | 3.64 | 3.06 | 0.0% | 0 of 90 | 227 |
| Oct to Dec 2025 | 3.61 | 0.81 | 3.77 | 3.20 | 0.0% | 0 of 92 | 227 |
| Jul to Sep 2025 | 3.51 | 0.83 | 3.73 | 2.96 | 0.0% | 0 of 92 | 226 |
| Apr to Jun 2025 | 3.68 | 0.72 | 3.86 | 3.22 | 0.0% | 0 of 91 | 218 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| New Jersey, Jan to Mar 2026 | 3.68 | 0.59 | 3.82 | 3.34 | 11.6% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| New Jersey, all employers | |||
| CNAs (nursing assistants) | $22.52 | $21.13 to $23.44 | 32,400 |
| LPNs and LVNs | $36.13 | $32.16 to $38.45 | 17,410 |
| Registered nurses | $51.20 | $47.94 to $61.41 | 92,680 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | New Jersey | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.7 | 8.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.1 | 0.6 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.7 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.0 | 2.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.6 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 21.7 | 8.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.2 | 5.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.3 | 12.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.0 | 24.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 10.1 | 8.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Complete Care at Harborage LLC's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (57.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
57.9% this home
Better than the national rate
US median of homes 51.5% · New Jersey: 130 better, 19 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 390 eligible stays.
13.5% this home
Worse than the national rate
US median of homes 10.7% · New Jersey: 2 better, 8 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 375 eligible stays.
9.2% this home
No different from the national rate
US median of homes 7.1% · New Jersey: 3 better, 13 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 254 eligible stays.
60.5% this home
Median of homes: New Jersey68.7% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 152 residents counted.
0.8% this home
Median of homes: New Jersey0.6% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 260 residents counted.
1.8% this home
Median of homes: New Jersey1.7% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 260 residents counted.
100.0% this home
Median of homes: New Jersey99.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 22 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: COMPLETE CARE AT HARBORAGE LLC. CMS links this home to Complete Care, a group of 85 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| PC Hmh Opco Holdngs LLC | 5% or greater direct ownership interest | Organization | 100% | 03/16/2023 |
| PC Hmh Holdings LLC | 5% or greater indirect ownership interest | Organization | 03/16/2023 | |
| Sms 2021 Trust | 5% or greater indirect ownership interest | Organization | 03/16/2023 | |
| Stein, Shalom | Indirect ownership interest | Individual | 03/16/2023 | |
| Stein, Shalom | Managing control - governing body | Individual | 03/16/2023 | |
| Stein, Shalom | Corporate officer | Individual | 03/16/2023 | |
| Elsebai, Karina | Operational/managerial control | Individual | 03/16/2023 | |
| Lifschutz, Michael | Operational/managerial control | Individual | 03/20/2024 | |
| Schwartz, Hershel | Operational/managerial control | Individual | 03/16/2023 | |
| Weissman, Simcha | Operational/managerial control | Individual | 08/01/2024 | |
| Stein, Shalom | Trustee of the SNF | Individual | 03/16/2023 | |
| Hmh Hospitals Corporation | Adp of the SNF | Organization | 03/16/2023 | |
| Elsebai, Karina | Adp of the SNF | Individual | 03/16/2023 | |
| Lifschutz, Michael | Adp of the SNF | Individual | 03/20/2024 | |
| Schwartz, Hershel | Adp of the SNF | Individual | 03/16/2023 | |
| Starks, Lamons | Adp of the SNF | Individual | 02/17/2025 | |
| Weissman, Simcha | Adp of the SNF | Individual | 08/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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