Complete Care At Prospect Heights Llc
Inspection Findings
F-Tag F0584
F 0584 Level of Harm - Minimal harm or potential for actual harm
rug on the hallway stained with large, dark, brownish substance, handrails scuffed and with wear, and wall stained with brown substances. S #3 observed by room [ROOM NUMBER] (Resident R523) hallway with the wallpaper peeling. S #3 observed 5th floor hallways throughout some areas with dark stains on the rug, including the rug around the nursing station. S #3 observed the rug and walls around Rooms 505-507 stained throughout some spots. S #3 observed the 5th floor dining room area with peeling wallpaper.
Residents Affected - Some
On 1/22/26 at 10:53 AM, S #3 in the presence of the 5th floor RN/UM observed the stained rugs and walls and she confirmed that she addressed the concerns with the LNHA, Maintenance Director, and DON every time I get a new patient, I verbally expressed my dilemma in the morning meeting, and it had been like that over a year, no matter how much they shampoo it did not come off. The RN/UM further stated They tell me
they know.
On 1/22/26 at 11:09 AM, S #3 interviewed the Housekeeping Director/ Maintenance Director, and she stated that the rugs were [AGE] years old, even it was shampooed every two weeks, the floor stains did not come out. She further stated I have to look at the peeled wallpaper. If we use bleach, it gets worse. I've been asking them to change the wallpaper.
On 1/22/26 at 11:55 AM, S #3 observed the 6th floor main dining room with peeled wallpaper on the ceiling near the television and the walls. S #3 observed the rug area by the windows on the right side, stained with brownish substance.
On 1/28/26 at 2:44 PM, the survey team met with the LNHA and the DON, and S #3 notified them of the above concerns regarding the environment.
A review of the facility's Safe and Homelike Environment Policy, that was provided by the LNHA, with a reviewed date of 9/1/25, revealed under policy, in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment.This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Under definitions: Comfortable and safe temp levels means that the ambient temp should be in a relatively narrow range that minimizes residents' susceptibility to loss of body h eat and risk of hypothermia/hyperthermia and is comfortable for the residents.
Environment refers to any environment in the facility that is frequented by residents, including the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.
Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in completion of the activities of daily living.
On 1/29/26 at 1:50 PM, the survey team met with the LNHA, DON and [NAME] President of Clinical Services (VPoCS) for exit conference, and there was no additional information provided by the LNHA.
NJAC 8:39-31.2(e); 31.4(a)(b)(e)(f)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
01/29/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Prospect Heights LLC
336 Prospect Ave Hackensack, NJ 07601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0725
F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
incontinence briefs. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/9/25, the brief
interview for mental status (BIMS) score was 15 out of 15, which reflected that the resident was cognitively intact. Section GG Functional Abilities: under toileting hygiene was coded 1 (dependent) and toilet transfer was coded 1. Section H Bladder and Bowel was coded 3 (always incontinent) for both bladder and bowel.
Section M Skin Conditions=no skin impairment. On 1/23/26 at 12:16 PM, the surveyor reviewed the toileting hygiene task of the CNA in the electronic medical records and revealed, from 1/10/26 to 1/22/26, the question, the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. were checked off every shift. In addition, the toileting hygiene task revealed on 1/23/26, there was only one shift that signed off the task at 00:17 (12:17 AM),reflected that the resident was dependent, and required the assistance of two or more helpers for the resident to complete the activity. Further review of the toileting hygiene task revealed on 1/23/26, there was no documented evidence that the 7 AM-3 PM shift had signed off the task to reflect that care was provided, and no documented evidence that after 12:17 AM of 1/23/26, that incontinence care was provided. On 1/23/2026 12:20 PM A review of the provided List of Incontinent Residents by the Licensed Nursing Home Administrator (LNHA) revealed that Resident #13 was included. A review of the provided nursing staffing schedule for 1/23/26, revealed a census of 112 and there were two CNAs on the 5th floor in 7 AM - 3 PM shift. On 1/28/26 at 1:47 PM, the survey team met with the LNHA and Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with Resident #13. On 1/29/26 at 10:29 AM, the surveyor met with the LNHA and DON for QAPI (Quality Assurance Performance Improvement) meeting and discussed the Facility Assessment that was provided to the surveyor with regard to staffing requirements. The LNHA confirmed that staffing concern had been part of facility's QAPI, and he was aware that the facility at times were unable to meet the New Jersey (NJ) required minimum staffing requirements or ratio for 1 CNA:8 Residents for 7 AM-3 PM, 1 CNA:10 Resident for 3 PM-11 PM, and 1 CNA:14 Residents for 11 PM-7 AM. On 1/29/26 at 11:43 AM, the survey team met with the LNHA and the DON for responses. The DON informed the surveyors that after inquiry with the staff, it was found out that it was the first time the resident had asked for double incontinence briefs, and CP was updated to include the resident's request after surveyor's inquiry and
observation. The DON further stated that aid was provided a one on one in service. A review of the facility's Activities of Daily Living Policy that was provided by the DON, with a reviewed/revised date of 10/1/25, reflected under policy statement, residents will provide with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Policy Interpretation and Implementation.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene.c.
Elimination (toileting).A review of the facility's Incontinence Policy that was provided by the LNHA, with a reviewed/revised date of 9/1/25, reflected, based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines: .4. Residents that are incontinent with bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. On 1/29/26 at 1:50 PM, the survey team met with the LNHA, DON and [NAME] President of Clinical Services for exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-25.2(b); 27.2(h)
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COMPLETE CARE AT PROSPECT HEIGHTS LLC in HACKENSACK, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HACKENSACK, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPLETE CARE AT PROSPECT HEIGHTS LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.