Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Prospect Heights Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain required environmental standards in multiple resident-accessible areas. Dining/activity rooms on upper floors were documented at temperatures below the acceptable range, and a dining room that leadership described as decommissioned had no signage and remained accessible. In resident rooms, a loose pipe was found on the floor, privacy curtains were not properly hooked, and a ceiling vent had visible grayish buildup. A hallway linen cart was left partially uncovered with dried substances and stains on its cover. On two upper floors, hallways, rugs, walls, handrails, and dining rooms showed large dark stains, peeling wallpaper, and worn surfaces, with nursing and housekeeping leadership acknowledging that these conditions had persisted despite repeated cleaning and prior verbal reports. These findings conflicted with the facility’s own policy requiring a safe, clean, comfortable, and homelike environment in all resident areas.
The facility failed to provide sufficient CNA staffing to ensure timely and appropriate incontinence care for a resident who was cognitively intact, always incontinent of bladder and bowel, and dependent for toileting hygiene and transfers. On one unit, two CNAs were assigned to 28 residents, and a CNA reported having about 14 residents and not being finished with morning care. During an incontinence round, an RN/Unit Manager found the resident wearing double incontinence briefs that were saturated with urine, with wet pads and linens and a urine odor, despite no care plan entry or documentation that the resident had requested double briefs. Review of electronic CNA documentation showed toileting hygiene tasks were routinely signed off as completed, but on the day of observation only a single entry was recorded shortly after midnight, with no further documentation of incontinence care by the day shift, even though the resident was listed as incontinent and only two CNAs were scheduled on that floor.
Three residents with significant medical conditions did not have their weights collected and documented as ordered by physicians, with only one weight recorded for each or none after admission, and no explanation documented in the medical record. Staff interviews and job descriptions confirmed that policies and responsibilities for weight monitoring were in place, but these were not followed.
The facility failed to screen two EMTs and ensure they wore PPE while transporting a resident on a COVID unit. The EMTs were not informed of the outbreak or required to wear masks, contrary to facility policy. The Receptionist admitted to not screening them, and the DON confirmed the expectation for screening all entrants.
A facility failed to disinfect a multi-use glucometer with an EPA-registered disinfectant, using alcohol wipes instead, which increased the risk of blood-borne pathogen transmission among residents. Additionally, improper disposal of PPE was observed, with used PPE being discarded in hallway trash receptacles instead of inside isolation rooms, contrary to facility policy. These practices were inconsistent with infection control protocols, as confirmed by the DON and housekeeping staff.
A facility failed to maintain appropriate physician orders and labeling for a resident's oxygen use. The resident was observed using oxygen without an active order, and the oxygen tubing was unlabeled and improperly handled. A nurse confirmed the lack of proper labeling and contamination of the tubing, and it was noted that the last active order for oxygen had expired over a month ago.
The facility did not post the Nursing Home Resident Care Staffing Report in areas accessible to residents, as required by policy. Observations showed no postings on resident floors, and interviews with the DON and Administrator confirmed the absence of postings where residents lived, potentially preventing residents from knowing staffing levels.
A facility did not effectively implement and revise care plan interventions for a resident experiencing significant pain, leading to a decline in condition. Despite having orders for pain medication and a care plan indicating pain management strategies, the resident reported high pain levels on multiple occasions without appropriate intervention. The lack of adequate pain management and care plan revision resulted in a decline in the resident's functional abilities and overall well-being, contrary to the facility's pain management policy.
The facility did not consistently follow the care plan, evaluate pain, or ensure proper administration of pain medications for a resident experiencing pain from various conditions. Pain assessments were not always conducted or documented appropriately, and medication records showed discrepancies where reported pain levels were not matched with the administration of prescribed pain medication. Occupational Therapy notes indicated continuous complaints of pain and a decline in interventions due to pain and fatigue. Communication gaps between the Occupational Therapy team and nursing staff were identified, highlighting challenges in managing pain with only PRN medication. The facility's policy emphasized the need for an interdisciplinary approach to pain management, including both pharmacological and non-pharmacological interventions.
The facility failed to accurately encode a resident's wound in the MDS assessment. A resident admitted with diagnoses including Difficulty in Walking and Protein Calorie Malnutrition was documented as not having a pressure ulcer in the MDS assessment. However, records showed the resident had a sacral pressure ulcer, and preventative skin care orders were in place. The MDS Coordinator confirmed the miscoding by previous staff.
A resident with multiple medical conditions was found in a neglected state, with a soaked incontinence brief and fecal matter on their back, due to the facility's failure to provide adequate toileting assistance. The CNA responsible did not check or change the resident since the beginning of the shift, citing staff shortages. Facility policies requiring regular checks and immediate changes were not followed.
The facility failed to provide adequate staffing, resulting in a resident with multiple health issues being left in a soiled and wet condition for several hours. The resident's care plan and MDS indicated the need for assistance with ADLs and incontinence care, which were not met due to staffing shortages.
Failure to Maintain Safe Temperatures and Clean, Homelike Environment in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident-accessible areas. Surveyors observed that thermostats in the 3rd and 4th floor dining/activity rooms showed temperatures of approximately 67°F and 66.7°F, and a later temperature check in the 3rd floor dining room showed 64°F, below the facility’s own policy definition of comfortable and safe temperature levels and below the CMS temperature range referenced in state guidance. The 3rd floor dining room, which the LNHA stated was decommissioned and not in use, had no signage or notifications indicating it was closed, and the doors could be opened by surveyors, visitors, residents, and staff. Facility environmental temperature and safety rounds documentation did not include temperature measurements for any dining/activity areas on any floor. Additional environmental deficiencies were observed in resident rooms and common areas. In one resident room, a white pipe was found on the floor, which a CNA stated was likely from the metal cover under the sink. On a 6th floor hallway near a resident room, a linen cart was observed not fully covered, with whitish and blackish dried substances and a brownish stain on the cover; the Director of Recreation and a CNA acknowledged the cart should not be left open and that the white stain was from soap that had burst. In two separate resident rooms on the 4th floor, privacy curtains were hanging and not properly hooked on the rods, and in one of those rooms, a ceiling vent was observed with an accumulation of grayish substances upon entry. Surveyors also documented widespread issues with cleanliness and maintenance of floors, walls, and dining areas on the 5th and 6th floors. On the 5th floor, between specific rooms, the hallway rug was stained with a large dark brownish substance, handrails were scuffed and worn, and walls were stained with brown substances; wallpaper was peeling in at least one hallway area, and rugs throughout the 5th floor, including around the nursing station and near several rooms, had dark stains. The 5th floor dining room area had peeling wallpaper. The 5th floor RN/UM reported she had repeatedly raised these concerns with the LNHA, Maintenance Director, and DON for over a year and that shampooing every two weeks did not remove the stains. On the 6th floor, the main dining room had peeling wallpaper on the ceiling near the television and on the walls, and the rug area by the windows was stained with a brownish substance. These conditions were inconsistent with the facility’s Safe and Homelike Environment Policy, which requires a safe, clean, comfortable, and homelike environment in all resident-frequented areas, including hallways and dining/activity rooms.
Insufficient CNA Staffing Leads to Untimely Incontinence Care and Undocumented Double Brief Use
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to ensure timely and appropriate incontinence care, as evidenced by staffing levels and the condition of an incontinent resident. On one morning, the Nursing Home Resident Care Staffing Report showed a census of 118 residents on the 7 AM–3 PM shift with a CNA-to-resident ratio of 1:14.8. On the 5th floor, there were 28 residents and only two CNAs assigned. When interviewed, a CNA on that unit stated she had about 14 residents, described the assignment as hard, and reported she was not finished with morning care. On another day, the posted staffing report showed a census of 117 with 10 CNAs on the 7 AM–3 PM shift, for a ratio of 1 CNA to 11.7 residents. The facility’s own leadership later acknowledged that staffing concerns and at times not meeting New Jersey minimum staffing ratios were known issues. During an incontinence round on the 5th floor, the RN/Unit Manager confirmed that a resident was incontinent of both bladder and bowel and obtained the resident’s permission to check the incontinence brief. The RN/Unit Manager and surveyor observed that the resident was wearing double incontinence briefs that were wet with urine. The RN/Unit Manager also found that the resident’s pads, folded linen, and cloth-type chuck under the resident were wet beyond the pads, and there was a noticeable urine odor. The RN/Unit Manager stated she was unaware that the resident had requested double briefs and indicated that double briefs were not allowed unless specifically requested by the resident and included in the care plan. She further stated she was unsure whether this preference was in the care plan. The surveyor was unable to interview the CNA assigned to the resident at that time. Record review for this resident showed diagnoses including type 2 diabetes mellitus without complications, COPD unspecified, need for assistance with personal care, and difficulty in walking. The care plan identified a focus on potential impairment to skin integrity with an intervention to assist with toileting needs, but there was no care plan entry documenting a preference for double incontinence briefs or any documented evidence that the resident had requested them. The most recent quarterly MDS showed the resident was cognitively intact (BIMS 15/15), always incontinent of bladder and bowel, and dependent for toileting hygiene and toilet transfer, with no documented skin impairment. Review of CNA electronic documentation for toileting hygiene from 1/10/26 to 1/22/26 showed the task was checked off every shift as completed with the resident dependent and requiring assistance of two or more helpers. However, on 1/23/26, only one shift at 12:17 AM documented toileting hygiene, and there was no documentation by the 7 AM–3 PM shift or any evidence of incontinence care after 12:17 AM that day, despite the resident being listed on the facility’s list of incontinent residents and only two CNAs being scheduled on the 5th floor for that shift.
Failure to Obtain and Document Resident Weights per Physician Orders
Penalty
Summary
The facility failed to follow professional standards of clinical practice regarding the assessment and documentation of residents' weights and the implementation of physician orders. Specifically, three residents with various medical conditions, including urinary tract infection, congestive heart failure, hypertension, respiratory failure, COVID-19, pneumonia, anemia, and muscle weakness, had physician orders for weights to be collected on admission and then weekly for four weeks. However, for each of these residents, weights were either not collected as ordered or were only collected once, with no documentation in the progress notes explaining the omissions. Interviews with facility staff, including the Dietitian and Director of Nursing, revealed that there were established expectations and policies for weight monitoring and documentation, including procedures for documenting refusals or missed weights. Job descriptions for CNAs, LPNs, RNs, and the Dietitian outlined responsibilities related to weighing residents and documenting or reporting weight changes. Despite these policies and procedures, the required weights were not consistently obtained or documented, and there was no evidence in the medical record to explain the missed assessments.
Failure to Screen and Enforce PPE Use for EMTs
Penalty
Summary
The facility failed to properly screen outside vendors and ensure that Personal Protective Equipment (PPE) was worn on the COVID unit, specifically involving two Emergency Medical Technicians (EMTs) who were observed transporting a resident. The resident's electronic medical record indicated an admission date, but the report does not specify any medical history or condition at the time of the deficiency. During an observation, the EMTs were seen on the facility elevator without masks while transporting the resident to the third floor, which was under COVID precautions. Interviews revealed that the EMTs were not informed of the COVID outbreak, nor were they screened or instructed to wear masks on the affected units. The facility Receptionist admitted to not properly screening the EMTs, and the Director of Nursing (DON) confirmed the expectation that all individuals entering the facility should be screened according to the COVID outbreak protocol. The facility's policy for emergent infectious diseases required screening and temperature checks for all administrative staff, contractors, and visitors before entering the facility, which was not followed in this instance.
Infection Control Deficiencies in Glucometer Disinfection and PPE Disposal
Penalty
Summary
The facility failed to properly disinfect a multi-use glucometer with an EPA-registered disinfectant, as observed during a survey. A Licensed Practical Nurse (LPN) was seen using an alcohol wipe to clean the glucometer after using it on a resident, which is not in accordance with the facility's policy that requires the use of an EPA-registered disinfectant effective against HIV, Hepatitis C, and Hepatitis B. This practice was observed on the East medication cart, where the same glucometer was used for multiple residents, increasing the risk of transmitting blood-borne pathogens. The LPN confirmed that she had been educated to use alcohol pads for disinfection, which contradicts the facility's policy. Additionally, the facility did not ensure proper doffing and disposal of Personal Protective Equipment (PPE) to prevent infection spread. Observations revealed that a visitor exiting a resident's room on isolation precautions disposed of used PPE in hallway trash receptacles instead of inside the room. The facility's policy mandates that PPE should be disposed of in appropriate waste receptacles within the room to prevent contamination. The Director of Nursing (DON) confirmed that the expectation was to dispose of PPE inside the rooms, but the trash cans were placed in the hallway by housekeeping staff. The survey also noted that the facility had two rooms on isolation precautions, with signage and PPE equipment posted on the doors. However, there was inconsistency in the availability of trash receptacles for PPE disposal inside these rooms. One room had a large trash can near the door, while the other did not, leading to improper disposal practices. The Housekeeping Director stated that training was provided to staff on cleaning isolation rooms, but the placement of trash receptacles was not consistent with the facility's infection control policy.
Removal Plan
- Facility wide staff education on proper disinfection of multi-use glucometers
Failure to Maintain Proper Oxygen Orders and Labeling
Penalty
Summary
The facility failed to ensure that a resident had the appropriate physician orders for the use of oxygen and that the oxygen tubing was properly labeled. The electronic medical record for the resident showed no active order for oxygen use, yet the resident was observed using oxygen at 2 liters per minute from a wall delivery system. The oxygen tubing and water humidifier were unlabeled, and the tubing was improperly wrapped around the bed's side rail, with an oxygen mask left uncovered and dangling to the floor. A staff nurse administered medication to the resident without addressing the oxygen system. A Licensed Practical Nurse confirmed that the oxygen should be continuously administered via nasal cannula and acknowledged the lack of proper labeling and contamination of the dangling tubing. It was also confirmed that the resident did not have any active oxygen orders, with the last order having expired over a month prior.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Nursing Home Resident Care Staffing Report was posted in areas accessible to residents, as required by their policy. The policy, revised on 08/14/24, mandates that nurse staffing information be readily available in a readable format to residents and visitors at any time. However, an observation on 09/25/24 at 10:30 AM revealed that there was no staff posting on the third, fifth, and sixth floors where residents lived. During interviews, the Director of Nursing (DON) indicated that the posting should be on the clerk's desk downstairs and sometimes in the window next to activities, but both the DON and the Administrator confirmed that it was not available on the resident floors. This oversight had the potential to prevent residents from knowing the staffing levels provided for all 96 residents in the facility.
Inadequate Pain Management and Care Plan Revision
Penalty
Summary
The facility failed to implement and revise care plan interventions for Resident #1, who was experiencing pain resulting in a decline in condition. Despite the CP indicating pain related to a disease process and interventions to address pain symptoms, the facility did not adequately manage Resident #1's pain when it exceeded a Pain Scale (PS) of 3. Orders for pain medication were in place, but Resident #1 reported significant pain levels on multiple occasions, including a PS of 9 on 2/2/24, without appropriate intervention or revision of the care plan. Documentation revealed Resident #1's steady decline in skilled interventions due to pain and fatigue, with reports of significant pain levels in various body parts. The facility's failure to address Resident #1's pain adequately led to a decline in functional abilities and overall well-being. Despite reports of pain and weakness, there was no indication that the care plan was revised or that stronger pain management measures were considered, as required by the facility's policy on pain management and comprehensive care planning.
Inconsistent Pain Management and Documentation
Penalty
Summary
The facility failed to consistently follow the care plan, evaluate pain, and ensure proper administration of pain medications for Resident #1, who was experiencing pain related to various conditions including falls, difficulty in walking, and adult failure to thrive. Despite the care plan indicating the need for analgesia as per physician's orders, there were instances where pain assessments were not conducted or documented appropriately. The medication administration records revealed discrepancies where Resident #1 reported pain levels above the prescribed threshold, but there was no indication that the ordered pain medication was administered accordingly. Documentation from the Occupational Therapy Treatment Encounter Notes indicated Resident #1's continuous complaints of pain and decline in skilled interventions due to pain and fatigue. The Certified Occupational Therapy Aide (COTA) acknowledged the lack of communication to nursing regarding the resident's pain and emphasized the importance of documenting such interactions for proper care coordination. The facility's policy on pain management highlighted the need for comprehensive, person-centered care plans addressing individual pain management needs, including both pharmacological and non-pharmacological interventions. During interviews with the Occupational Therapist/Director of Rehab (OT/DOR), COTA, and LPNs, it was revealed that there were communication gaps regarding Resident #1's pain status and management. LPN #3 mentioned the challenges in managing Resident #1's pain with only PRN medication and the resident's distress during episodes of severe pain. The facility's policy emphasized the interdisciplinary approach to pain management, incorporating non-pharmacological interventions alongside pharmacological treatments tailored to each resident's specific pain needs.
Inaccurate MDS Assessment of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to accurately encode a resident's wound in the Minimum Data Set (MDS) assessment for one of the three residents reviewed for MDS accuracy. Specifically, Resident #1 was admitted with diagnoses including Difficulty in Walking, Adult Failure to Thrive, and Protein Calorie Malnutrition. The MDS assessment dated 12/10/23 indicated that the resident did not have a pressure ulcer. However, a review of the resident's Skin Integrity/Diagram (SID) dated 12/8/23 showed that the resident had a sacral pressure ulcer described as redness. Additionally, the Order Summary Report (OSR) dated 4/15/24 revealed an order for preventative skin care, including the application of barrier cream after cleansing with soap and water every shift and as needed after each incontinent episode, starting from 12/6/23. The Treatment Administration Record (TAR) for December 2023 confirmed that the barrier cream was applied to the resident's skin from 12/7/23. During interviews with the surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the documentation on the SID, and the MDS Coordinator (MDSC) confirmed that the previous MDS staff, who no longer work at the facility, had miscoded the 12/10/23 assessment in Section M. The facility's policy titled MDS Completion and Submission Timeframes, dated 10/2019, indicated that the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. This discrepancy in the MDS assessment led to the deficiency noted in the report.
Failure to Provide Adequate Toileting Assistance
Penalty
Summary
The facility failed to provide adequate assistance in toileting services to a resident, leading to a deficiency. The resident, who was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, muscle weakness, and a need for assistance with personal care, was found in a severely neglected state. During a skin check, the resident was observed lying in a soaked and wet incontinence brief, with fecal matter on their back, and stained bed linens. The resident's care plan indicated a need for assistance with hygiene and comfort measures due to impaired mobility and incontinence, but these needs were not met. The CNA responsible for the resident admitted to not checking or changing the resident's incontinence underwear since the beginning of the shift, citing staff shortages as the reason for the oversight. The facility's policy requires residents to be checked for wetness every two hours and changed immediately if soiled, but this protocol was not followed. The facility's documentation and interviews with staff revealed that the third floor, where the resident was located, had three CNAs assigned to 27 residents on the day of the incident. The CNA job description and facility policies emphasize the importance of keeping residents dry and providing necessary perineal care to prevent skin breakdown and maintain hygiene. However, the failure to adhere to these policies resulted in the resident being left in an unsanitary and uncomfortable condition, highlighting a significant lapse in the standard of care provided by the facility.
Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, specifically Resident #2, who was admitted with diagnoses including Urinary Tract Infection, Metabolic Encephalopathy, Muscle Weakness, and required assistance with personal care. On 4/15/24, during a skin check at 10:36 am, Resident #2 was found lying in bed with a soaked and wet incontinent brief, and the bed sheets were stained with urine and feces. The resident's lower to mid-back had fecal matter, indicating that the resident had not been checked or changed since the beginning of the shift at 7:00 a.m. The CNA assigned to Resident #2 confirmed that she did not provide care until 10:36 a.m. due to being short-staffed that day. The third floor had 27 residents and only 3 CNAs on duty, which contributed to the inadequate care provided to Resident #2. The care plan for Resident #2, initiated on 4/9/24 and revised on 4/15/24, indicated that the resident had actual impairment to skin integrity related to impaired mobility, incontinence, and nutritional concerns. The Minimum Data Set (MDS) assessment dated 4/13/24 indicated that Resident #2's cognition was moderately impaired and required assistance with Activities of Daily Living (ADLs). The MDS also noted that the resident was incontinent of bowel and bladder. The CNA job description included specific functions such as making residents comfortable, keeping them dry, and assisting with bowel and bladder functions, which were not adequately performed due to staffing shortages. This deficiency highlights the facility's failure to provide sufficient nursing staff to meet the needs of its residents, as required by NJAC 8:39-27.1(a).
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How nearby facilities compare on the same public inspection record.
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