State inspectors discovered Resident #13 on January 23, 2026, in a brief soiled with both urine and feces. The resident had scored 15 out of 15 on a mental status assessment in December, indicating full cognitive function.
Electronic records showed staff had checked off toileting hygiene tasks every shift from January 10 through January 22. But on January 23, only one entry appeared at 12:17 AM, indicating the resident needed assistance from two or more helpers.
No documentation existed showing the day shift from 7 AM to 3 PM had provided any incontinence care that day. No care was recorded after 12:17 AM.
The resident was classified as "always incontinent" for both bladder and bowel according to facility assessments. Despite this, staff failed to follow through on documented care requirements.
When inspectors questioned administrators about the double-soiled brief, facility leaders acknowledged it was "the first time the resident had asked for double incontinence briefs." The Director of Nursing said staff updated the care plan only after inspectors raised concerns.
The facility operates with chronic understaffing that violates New Jersey requirements. Licensed Nursing Home Administrator confirmed the facility "at times were unable to meet" state minimums of one nursing assistant for every eight residents during day shifts.
On January 23, census records showed 112 residents with only two nursing assistants covering the entire fifth floor during the day shift. State regulations require one assistant for every eight residents from 7 AM to 3 PM, one for every ten residents from 3 PM to 11 PM, and one for every fourteen residents overnight.
Facility policies require staff to provide "appropriate care and services" for residents unable to perform daily activities independently. The incontinence policy specifically states residents "will receive appropriate treatment and services" based on comprehensive assessments.
The policy mandates that incontinent residents receive "appropriate treatment to prevent infections and to restore continence to the extent possible."
Administrators acknowledged staffing concerns were part of the facility's ongoing quality improvement discussions. The Licensed Nursing Home Administrator said he was aware of the facility's inability to meet state staffing ratios.
The Director of Nursing told inspectors she provided "one on one in service" training to the aide involved after the incident came to light. She offered no explanation for why documented care requirements were ignored for over half a day.
Facility records showed Resident #13 was included on the administrator's list of incontinent residents, indicating staff were aware of the person's needs. The resident's assessment showed dependence for toilet transfers and toileting hygiene, requiring staff assistance for basic care.
The inspection occurred following a complaint. State inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
Complete Care at Prospect Heights operates as a limited liability company in Hackensack. The facility's president of clinical services attended the exit conference but provided no additional information about the care failures.
The resident's skin assessment showed no impairment at the time of the most recent evaluation in December. However, prolonged exposure to waste in incontinence products creates significant risk for skin breakdown and infection, particularly for residents who cannot reposition themselves.
Federal and state regulations require nursing homes to ensure residents receive necessary services to maintain personal hygiene and prevent deterioration of existing conditions. The failure to provide documented incontinence care for over twelve hours represents a basic breakdown in required services.
The facility's own policies acknowledge the importance of preventing infections and maintaining hygiene for incontinent residents. Staff's failure to follow through on documented care plans left a cognitively aware resident sitting in waste for an extended period without assistance.
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.
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