Complete Care at Prospect Heights: Staffing Failures - NJ
The admission came after inspectors documented that Resident 13, who is fully incontinent of both bladder and bowel and requires two staff members to assist with any toileting, went without documented incontinence care for the entire morning shift on January 23, 2026, at Complete Care at Prospect Heights LLC.
Inspectors reviewed the electronic medical records on January 23 at 12:16 PM and found that the last documented toileting hygiene task for the resident had been signed off at 12:17 AM, just after midnight. Nobody had documented providing incontinence care on the 7 AM to 3 PM shift. The records showed the task had been checked off every shift from January 10 through January 22, but on the 23rd, the morning shift entry was simply absent.
The resident is coded as always incontinent and completely dependent on staff for toileting hygiene and transfers. Two or more helpers are required to complete the activity.
On the day the gap appeared in the records, the facility had two certified nursing assistants assigned to the entire fifth floor for the 7 AM to 3 PM shift. The building's census that day was 112 residents.
New Jersey requires a ratio of one CNA for every eight residents during the day shift. Two CNAs for a floor, in a building of that size, does not meet that standard. The Licensed Nursing Home Administrator confirmed to inspectors on January 29 that the facility was aware it sometimes could not meet the required ratios, not just for days but across all three shifts. The required minimums are one CNA to eight residents in the morning, one to ten in the afternoon, and one to fourteen overnight.
The administrator confirmed the staffing shortfall had been part of the facility's Quality Assurance Performance Improvement process. He was aware of it. It was documented. It kept happening anyway.
When surveyors met with the administrator and the Director of Nursing on January 29, the Director of Nursing offered an explanation for the missing care documentation. After asking staff about it, she said, they learned it was the first time the resident had requested double incontinence briefs. The care plan was updated to include that preference after the surveyor raised the issue. One aide received a one-on-one in-service.
The explanation addressed a preference. It did not explain why the morning shift hygiene task had no documentation at all.
The facility's own incontinence policy, revised as recently as September 2025, states that residents who are incontinent will receive appropriate treatment and services to prevent infections and restore continence to the extent possible. Its activities of daily living policy, revised in October 2025, commits to providing hygiene and toileting assistance to residents who cannot manage those tasks independently.
Both policies were provided to inspectors by facility leadership. Neither was followed for Resident 13 on the morning of January 23.
At the exit conference on January 29, the administrator, the Director of Nursing, and the President of Clinical Services were all present. No additional information was provided.
Resident 13 is always incontinent, needs two people to help with any toileting task, and cannot manage any part of the process alone. On a morning when the floor was short-staffed and the documentation shows no hygiene care was provided, the record contains no explanation of what happened to that resident between midnight and the afternoon, only silence where a completed task should have been.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Prospect Heights LLC from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
COMPLETE CARE AT PROSPECT HEIGHTS LLC in HACKENSACK, NJ was cited for violations during a health inspection on January 29, 2026.
Nobody had documented providing incontinence care on the 7 AM to 3 PM shift.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.