Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Harborage Llc during CMS and state inspections, most recent first.
Physical abuse of a resident with severe cognitive impairment, trach, and ventilator dependence occurred when a respiratory therapist was captured on hidden-camera video pushing the resident’s hand down, throwing a towel on the resident’s face, pulling and twisting the resident’s hands, hitting the resident on the face and head, and forcibly holding the resident down. The resident later had ED findings of contusions and a subdural hematoma, and the facility’s investigation determined the staff member’s actions were not consistent with policy.
Failure to Report Injuries of Unknown Origin: The facility did not report multiple injury events involving two residents with severe cognitive impairment and total dependence for ADLs. One resident had bruising to the cheek after pulling at trach tubing and another cheek bruise after return from ER for GT placement; a second resident had forehead bruising after leaning against a side rail. The investigations found no staff misconduct, but the incidents were not reported to NJDOH.
Incomplete abuse investigations for resident injuries: The facility did not complete thorough I/A reviews to rule out abuse for two residents with severe cognitive and physical impairment. One resident had bruising to the cheek after returning from the ER and another episode of facial injury after pulling at trach tubing, but one event had no I/A report and the other lacked documented prevention interventions. A second resident developed a forehead bruise after leaning against a side rail, yet the investigation included only one nurse statement and no additional staff statements.
Surveyors found multiple medication handling and documentation failures involving controlled meds and other drugs. An RN did not sign the narcotic log when removing and administering Hydromorphone, left an unlabeled Oxycodone/APAP tablet in a med cup after a resident refused it, and a patch was thrown in the trash instead of being properly disposed of. An LPN also failed to sign the narcotic log when removing controlled meds, and another LPN administered insulin without timely eMAR documentation, leaving orders overdue on the screen.
Surveyors observed a med pass with 4 nurses and found a 13.33% med error rate. One RN gave an OTC multivitamin instead of ordered Strovite One and initially selected the wrong Lidoderm strength for a resident’s patch orders, while another RN mismeasured Pro-Stat Oral Liquid and did not administer the full 30 mL dose to another resident. The observed errors involved incomplete or incorrect med preparation and administration that did not follow the ordered dose and strength.
The facility failed to promptly notify and document notification to the resident representative for two residents: one who died and one who had an unwitnessed fall. The deceased resident had multiple serious diagnoses, and the chart showed hospice, the UM, and supervisor were notified, but no record of RR notification. For the resident who fell, the LPN documented the assessment and return to bed, but the RR was not documented as notified until the next day, and staff gave inconsistent accounts of when the family was contacted.
A resident’s floor mat was repeatedly observed dirty, stained, and wet, and a CNA said housekeeping had been called but the mat was still dirty. In addition, a resident council member reported a morning towel shortage, and the 4th floor unit had 63 residents but the 7-3 cart listed only 60 towels; the supply closet had no towels while the laundry room had towels being processed and folded.
A facility failed to complete a timely initial nursing assessment for a newly admitted resident, failed to document administration of a physician-ordered PRN Lomotil, and failed to consistently document and coordinate hospice services in the resident’s record. Surveyors found no baseline nursing notes for the first days after admission, no MAR signature or explanation for the omitted med, and gaps in weekly hospice documentation for a resident with severe cognitive impairment and multiple chronic conditions.
The facility failed to ensure medication rooms on the second, third, and fifth nursing units were free of expired medical products and items left open. Observations revealed expired items such as central line trays, Huber needles, sterile water vials, and glucose control solutions. The DON stated that unit managers should oversee medical supplies and expiration dates.
A facility failed to develop a comprehensive care plan for a resident prescribed psychoactive medications for depression and anxiety. The care plan lacked interventions for monitoring side effects or behaviors, contrary to facility policy. The DON confirmed the necessity of such interventions for residents on psychoactive medication.
A resident with end-stage renal disease and other conditions did not receive necessary medications during dialysis days due to a lack of communication and collaboration between the LTC facility and the dialysis center. Medications such as furosemide, carvedilol, and Humalog were not administered as scheduled, and the facility failed to ensure these were given or rescheduled, contrary to their policy.
The facility failed to secure medications on the fifth floor, with an unlocked medication cart left unattended and a rolling cart with insulin pens unsecured. An LPN admitted the cart was unlocked due to lost keys, and the Unit Manager confirmed the oversight with the insulin pens. The DON emphasized the expectation for staff to secure medications.
Two residents in an LTC facility were not provided with necessary repositioning and incontinence care, despite being at high risk for pressure ulcers. Observations showed extended periods without repositioning or checks, and documentation revealed missed care opportunities. Staff interviews confirmed inadequate monitoring, highlighting deficiencies in adherence to care plans and facility policies.
The facility failed to maintain accurate medical records for two residents, resulting in undocumented medication administrations. One resident's MAR lacked documentation for several medications, and interviews revealed no explanation for the omissions. Another resident's MAR showed multiple medications not administered as per orders, with the responsible LPN claiming they were given but not documented. The facility's policy requires accurate and timely documentation, which was not followed.
Physical abuse of a ventilator-dependent resident by a respiratory therapist
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident with a tracheostomy and ventilator dependence was free from physical abuse by a respiratory therapist. The resident had severe cognitive impairment, required total assistance with activities of daily living, and had diagnoses including chronic respiratory failure with hypoxia, COPD, adjustment disorder with anxiety, tracheostomy status, and gastrostomy status. The resident’s care plan identified impaired cognitive/communication function after a CVA, resistance to care related to anxiety and pulling out the trach, and behaviors including flailing arms and contracted hand resulting in unintentional injuries to the face, arms, and hands. Law enforcement notified the facility of an allegation of abuse after reviewing hidden-camera video placed in the resident’s room by a family member. The facility’s reportable event record stated that the facility was made aware of the alleged staff-to-resident abuse and that the respiratory therapist was immediately suspended pending investigation. The surveyor reviewed video footage from 4/28/26, 5/1/26, and 5/2/26 that showed the respiratory therapist pushing the resident’s hand down, throwing a towel on the resident’s face multiple times, pulling the resident’s hands by the wrists, holding the resident’s head and letting it drop on the pillow, hitting the resident on the face, twisting and bending the resident’s hand back, squeezing and bending the resident’s hand, pushing the resident’s arm down, squeezing a towel on the resident’s face while the resident was gasping for air, and forcibly holding the resident’s hand down on the bed. The resident’s hospital emergency department record dated 5/11/26 showed an admitting diagnosis of subdural hematoma and documented contusions to the face, left chest, and right arm. The CT head without contrast showed a right convexity subdural hematoma. The facility’s investigative summary concluded that the respiratory therapist was not returned to the facility because the reviewed video footage demonstrated behaviors not consistent with facility policy. The report identified the incident as physical abuse involving one resident.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report to the New Jersey Department of Health potential abuse related to multiple incidents of resident injuries of unknown origin. The deficiency involved 2 of 4 residents reviewed for abuse and neglect, specifically a resident with severe cognitive impairment, total dependence for ADLs, chronic respiratory failure, tracheostomy status, gastrostomy status, and a history of anxiety and resistive behavior during care. For one resident, the record showed a large bruise to the left cheek after the resident attempted to pull at tracheostomy tubing and struck themself in the face multiple times. A nursing note also documented skin discoloration from the left cheek down to the neck, and the resident could not recall what happened. The incident investigation concluded there was no evidence of abuse, neglect, or staff misconduct, but the event was not reported to NJDOH. For the same resident, another nursing note documented a bruise/ecchymosis to the left cheek after the resident returned from the emergency room following gastrostomy tube placement. That incident was also not reported to NJDOH. For a second resident with severely impaired cognition, short- and long-term memory problems, total dependence for ADLs, non-traumatic intracerebral hemorrhage, respiratory failure, tracheostomy status, and gastrostomy status, the record showed a bruise/discoloration to the forehead after the resident was observed leaning toward the side rail with the forehead resting against it. The investigation stated the bruise was consistent with accidental contact/pressure against the side rail related to positioning behavior and anticoagulant use, and this incident was also not reported to NJDOH.
Incomplete Abuse Investigations for Resident Injuries
Penalty
Summary
The facility failed to ensure complete and thorough investigations were completed to rule out abuse for multiple resident injury incidents involving two residents. For Resident #1, who had severely impaired cognition, total dependence for ADLs, chronic respiratory failure, tracheostomy status, gastrostomy status, COPD, and anxiety with episodes of pulling at the trach and flailing her arms, the surveyor reviewed injury events from March and April 2026. One incident involved a bruise to the left cheek noted after the resident returned from the ER following GT placement, and another involved a large bruise to the left cheek after the resident reportedly attempted to pull at the tracheostomy tubing and struck herself in the face multiple times. The investigation for the 4/16/26 injury to Resident #1 concluded there was no evidence of abuse, neglect, or staff misconduct, but the report did not identify interventions to prevent further injury. For the 3/21/26 bruise to Resident #1, there was no incident/accident report or investigation provided to the surveyor. The record showed only a progress note documenting the left cheekbone ecchymosis after the resident returned from the ER, with no new order received. For Resident #3, who had non-traumatic intracerebral hemorrhage, atrial flutter, gastrostomy status, respiratory failure, tracheostomy status, short- and long-term memory problems, severely impaired cognitive skills, and total dependence for ADLs, the surveyor reviewed an injury event involving a small bruise/discoloration to the forehead. The facility’s investigation stated the bruise was consistent with accidental contact/pressure against the side rail related to the resident’s positioning behavior and anticoagulant use, but the I/A report contained only one staff statement from the nurse who assessed the resident and no other staff statements were supplied to the surveyor.
Controlled substance tracking and medication documentation failures
Penalty
Summary
The facility failed to ensure consistent accountability and proper disposition of controlled substances and non-narcotic medications during medication cart inspections and medication pass observations. In one instance, RN #1 reviewed the controlled drug administration record for a resident’s Hydromorphone and Oxycodone-Acetaminophen and found discrepancies between the inventory log and the bingo card counts. RN #1 stated he had removed Hydromorphone from the resident’s inventory but had not signed the declining inventory log when it was removed or after administration. The eMAR showed the Hydromorphone had been administered earlier that morning, and the timing of the administration was discussed with RN #1. During the same observation, an Oxycodone-Acetaminophen tablet was found in a med cup in the med cart, outside the mounted double-locked narcotic box and unlabeled. RN #1 stated the resident had refused the medication and requested Hydromorphone instead, but the refusal was not documented on the eMAR and the medication was not disposed of. The ADON confirmed that the removal should have been signed on the declining inventory log, the refusal should have been documented, and the medication should have been disposed of by two nurses. In another observation, RN #2 removed two Lidocaine 4% patches, dated one, then threw both patches into the trash when she realized the wrong strength had been selected. The UM could not state where the patches should have been disposed of, and RN #1 stated they should have been placed in the drug disposal solution. A separate medication pass observation found an LPN removing controlled medications for another resident and not signing the declining inventory log when the medications were removed or after they were administered. The LPN later stated the log should have been signed right away. In another observation, an LPN administered Novolog and Lantus to a resident, but the eMAR remained unsigned for a period of time and the orders stayed highlighted as overdue on the computer screen. The LPN stated the medications had already been given earlier that day but had not been signed for, and the audit report showed the medications were documented hours after administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that medication administration errors remained below 5 percent. During an observed medication pass involving 4 nurses and 5 residents, surveyors identified 4 errors out of 30 opportunities, resulting in a 13.33% medication error rate. The deficient practice involved 2 residents and 2 nurses during direct observation of medication preparation and administration. For one resident, RN #1 prepared Strovite One and Lidoderm patches. The resident had orders for Strovite One, one tablet daily, and two Lidoderm 5% patches, one for the left leg and one for the left shoulder. RN #1 removed an opened multivitamin bottle from the med cart and stated it was a stocked OTC medication, then later stated she had substituted the ordered Strovite One with an OTC multivitamin that contained no folic acid because the pharmacy had not sent the ordered medication. RN #1 also removed two Lidocaine 4% patches, then later acknowledged the wrong strength had been selected and that the original orders for Lidoderm 5% and Lidocaine 4% were incomplete because they did not specify the quantity of patches or the exact locations for application. For another resident, RN #2 prepared Pro-Stat Oral Liquid ordered at 30 mL twice daily. Surveyors observed RN #2 pour the liquid while holding the med cup in the air, then read the meniscus after the cup was placed on a flat surface and found the amount was below 30 mL. RN #2 added more liquid, but after administration surveyors observed liquid remained in the cup, and RN #2 acknowledged the full dose had not been given. The facility’s medication administration policies required the six rights of medication administration and administration according to the order, but the observed actions did not follow those requirements.
Failure to Notify and Document Representative Notification for Death and Fall
Penalty
Summary
The facility failed to ensure the resident representative was notified of a significant change in condition and failed to document that notification in the medical record for two residents. One resident had diagnoses including acute respiratory failure, pleural effusion, anemia, heart failure, and malignant neoplasm of the bladder. The record showed the resident expired at 12:53 PM, and while hospice services, the Unit Manager, and supervisor were notified, there was no documentation that the resident’s representative was informed of the death. Interviews with hospice and facility leadership confirmed that the facility was responsible for notifying the representative, but documentation of that notification could not be provided. For another resident with diagnoses including a right pubic fracture, gait and mobility impairment, generalized weakness, dementia, heart failure, acute kidney failure, and chronic kidney disease, the record showed a fall in which the resident was found on the floor by a CNA. The nurse documented that the resident was confused, denied discomfort, had no visible injuries, vital signs were taken, the supervisor was notified, and the resident was returned to bed. However, there was no documentation in the nursing note that the resident representative was notified of the fall at that time. The fall investigation report later indicated the resident representative was notified the next day, approximately 18 hours later. Interviews with the DON, ADON, and LPN showed inconsistent accounts of when and how the representative was contacted, and the facility could not provide documentation that the primary emergency contact was notified. The facility’s policies stated that the resident representative or family member should be notified promptly of significant changes, including death and falls, and that such notification should be documented.
Dirty Floor Mat and Insufficient Towels
Penalty
Summary
The facility failed to maintain a resident’s environment in a safe, clean, comfortable, and homelike condition when Resident #221’s floor mat was observed dirty, stained, and wet in multiple places. On the first observation, the resident was lying in bed with the mat on the right side of the bed showing wet pools; on a later observation the same mat remained stained and wet; and on a third observation it was moved vertically by the window wall and was still stained with dried colored chunks and pieces. A CNA stated the mat had been dirty the prior day and that housekeeping had been called, and also acknowledged that the mat was still dirty at the time of interview. The report also identified a shortage of towels on the fourth floor unit. During resident council, an unsampled resident stated there was a shortage of towels in the morning and that only one towel was received, which was not enough, and that this had been an issue for months. The unit census was 63 residents, while the par list for the 7-3 shift showed 60 towels on the cart, which did not provide one towel per resident for morning care when the census exceeded 60. The list also showed 15 towels delivered to the unit supply closet at 10, 12, and 2, and the 3-11 and 11-7 shift carts each had 60 towels. Further observation of the fourth floor supply closet found no towels in the closet, while the laundry room contained seven carts with 15 towels each, approximately 45 towels on a table, and an additional pile of laundry being folded from the dryer. The DH stated that 50 dozen towels had been ordered and approved, but had not arrived as expected. The DH also stated that the expectation was for staff to prepare carts for later shifts and that some days the cart was incomplete depending on what came back from the floors to wash. The facility policy stated that linen pars should satisfy daily resident needs and that bath towels had a par level of 3.0 per resident.
Delayed Admission Assessment, Missed PRN Medication, and Incomplete Hospice Documentation
Penalty
Summary
The facility failed to ensure a timely initial nursing assessment was completed for a resident admitted with atrial fibrillation, cerebral infarction, type 2 diabetes mellitus, hypertension, and dementia. The record showed no initial nursing assessment was completed on the day of admission, and no nursing progress notes were documented for the first three days after admission to establish the resident’s baseline status. The surveyor reviewed the closed record and found the initial nursing assessment was not completed until several days after admission. The facility also failed to ensure a physician-ordered PRN Lomotil was administered as ordered for a resident whose record included diagnoses of atrial fibrillation, stroke, diabetes, hypertension, and dementia. The electronic MAR showed the order for Lomotil 2.5-0.025 mg by mouth every 12 hours as needed for diarrhea after stool for C-diff had been collected for one day, but there was no signature showing the medication was given. The progress notes also contained no documentation explaining why the medication was not administered or omitted. In addition, the facility failed to document, communicate, and coordinate hospice services in accordance with the resident’s plan of care for a resident with Alzheimer’s disease, chronic kidney disease, peripheral vascular disease, and functional quadriplegia. The resident’s MDS showed severe cognitive impairment and indicated hospice services were being received, and the care plan addressed hospice care, poor appetite, and difficulty chewing and swallowing. Surveyors found hospice notes in the miscellaneous section of the eMR but identified gaps in weekly hospice documentation, and hospice visit notes provided by the hospice agency were not included in the facility’s eMR. Interviews with facility and hospice staff confirmed that hospice documentation was not consistently maintained in the medical record and that communication between hospice and facility staff was not clearly defined.
Expired Medical Products Found in Medication Rooms
Penalty
Summary
The facility failed to ensure that medication rooms on the second, third, and fifth nursing units were free of expired medical products and items left open. During observations conducted with an LPN, several expired items were found in the resident care supplies across these units. On the second-floor nursing unit, expired items included central line trays with chloral prep, Huber needles, a microbore extension set, an IV securement kit, a 30ml sterile water syringe left open, an IV administration kit, and replacement caps. On the third-floor nursing unit, expired items included a Huber needle, sterile water vials, a specimen transport tube, lubricating jelly, and needleless connector caps. On the fifth-floor nursing unit, expired items included saline enema laxatives, micro scaffold collagen, germicidal alcohol wipes, and glucose control solutions. During an interview, the Director of Nursing stated that unit managers should be responsible for overseeing medical supplies and checking expiration dates. The presence of expired items in the medication rooms has the potential to increase the risk of infections due to expiration.
Failure to Develop Comprehensive Care Plan for Psychoactive Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed psychoactive medications. The resident was admitted with diagnoses of depression and anxiety and had physician orders for Divalproex Sodium for agitation, Mirtazapine for depression, and Buspirone for anxiety. However, the care plan did not include the use of these psychoactive medications or interventions for monitoring side effects or behaviors. The facility's policy requires a person-centered care plan to address medical, nursing, and psychosocial needs identified in the resident's comprehensive assessment. The Director of Nursing confirmed that residents receiving psychoactive medication should have a care plan with interventions for monitoring behaviors and reporting side effects.
Failure to Administer Medications During Dialysis
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center and did not administer necessary medications to a resident requiring dialysis. The resident, who had end-stage renal disease, congestive heart failure, hypertension, and diabetes, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. Despite having orders for medications such as furosemide, carvedilol, and Humalog, these were not administered on several occasions when the resident was out for dialysis. The Medication Administration Record (MAR) showed that furosemide was not given on multiple occasions in October, November, and December, as it was marked that the resident was out of the facility. Similarly, carvedilol and Humalog were also not administered during these times. The facility's policy required communication with the dialysis center regarding medication administration, but the dialysis center did not administer these medications, nor was there documentation of such administration. Interviews with nursing staff and the Director of Nursing revealed that the facility did not send medications to the dialysis center, and there was no arrangement for the dialysis center to administer them. The Director of Nursing confirmed that the physician should have been contacted to reschedule or withhold medications if necessary, but this was not done. The facility's policy emphasized the need for communication and documentation regarding medication administration, which was not adhered to in this case.
Medication Security Lapses on Fifth Floor
Penalty
Summary
The facility failed to ensure the security of medications on the fifth floor, leading to a potential risk of medication diversion and unauthorized access by residents. During an observation, a medication cart on the fifth floor south was found unlocked and unattended from 12:07 PM to 12:15 PM. The LPN responsible for the cart admitted that the keys were lost, and the cart had been left unlocked since 7:15 AM. The facility's policy requires medications to be stored in locked compartments and under the observation of the administering nurse during medication passes. Additionally, a plastic rolling cart with three insulin pens was observed unattended and unsecured on the fifth floor. The Unit Manager confirmed the oversight and acknowledged that the medications should not have been left unattended. The Director of Nursing stated that nursing staff are expected to keep medications secured and not leave them unattended, highlighting a lapse in adherence to the facility's medication storage policy.
Deficiency in Repositioning and Incontinence Care for Residents
Penalty
Summary
The facility failed to provide necessary repositioning and incontinence care for two residents, R139 and R108, who were dependent on assistance with activities of daily living (ADLs). R139, admitted with diagnoses including sepsis and muscle weakness, was observed in the communal area for extended periods without being repositioned or checked for incontinence, despite orders to turn and position every two hours to prevent pressure wounds. Documentation revealed significant gaps in care, with numerous missed opportunities for repositioning and incontinence checks. Interviews with staff confirmed that R139 was not adequately monitored or cared for during these periods. R108, diagnosed with Alzheimer's disease, was also observed in a Broda chair for several hours without being repositioned or checked for incontinence. The care plan for R108 indicated a high risk for pressure ulcer development due to immobility and incontinence, with interventions requiring weight shifting every 15 minutes. However, observations showed that these interventions were not consistently implemented, and documentation indicated infrequent toileting and incontinence care. Interviews with the Director of Nursing and other staff members highlighted a lack of adherence to care plans and facility policies regarding monitoring and care for residents at risk of skin breakdown. The facility's policy required regular checks for incontinence and repositioning to prevent skin deterioration, but these were not consistently followed, leading to deficiencies in the care provided to R139 and R108.
Failure to Document Medication Administration for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, R71 and R22, as part of their nursing services. For R71, the Medication Administration Record (MAR) lacked documentation for several medications, including Lasix, Sertraline, Divalproex, Memantine, and Donepezil, which were not administered on specific dates in November 2024. Interviews with the resident's representative and nursing staff revealed that there was no documentation or nurse notes explaining the missed administrations. The Director of Nursing (DON) was unaware of these omissions and attributed them to incomplete documentation, emphasizing that any missed or late medication should be documented in the MAR with a corresponding nurse note. Similarly, R22's MAR indicated that multiple medications, such as Allopurinol, Amlodipine, Cyclosporine, and others, were not administered as per physician orders on a specific date in October 2024. The DON, upon reviewing the MAR, found no documentation explaining the missed administrations. An LPN responsible for administering R22's medications claimed they were given but not documented. The facility's policy on the accuracy of medical records mandates that documentation should be accurate, relevant, and completed by the end of the shift in which care was provided, which was not adhered to in these cases.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near North Bergen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudsonview Health Care Center | 0.6 mi | ★★★★★ | 1 | 0 |
| The Riverside | 1 mi | ★★★★★ | 0 | 0 |
| Harbour View Senior Living Corp | 1.3 mi | ★★★★★ | 22 | 0 |
| The New Jewish Home, Manhattan | 1.8 mi | ★★★★★ | 0 | 0 |
| Amsterdam Nursing Home Corp (1992) | 1.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.