Inspection Reports for Complete Care At Prospect Heights Llc
336 Prospect Ave, NJ, 07601
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Mar 5, 2025
Visit Reason
The inspection was conducted based on complaints NJ00183692 and NJ00183376 alleging noncompliance with professional standards of care and staffing ratios at Complete Care at Prospect Heights LLC.
Findings
The facility was found not in compliance with federal and state regulations related to clinical care plans and staffing ratios. Deficiencies included failure to follow acceptable clinical practice standards for resident assessments and inadequate staffing levels for Certified Nurse Aides and nursing staff over multiple days.
Complaint Details
Complaint numbers NJ00183692 and NJ00183376 triggered the visit. The facility was found deficient based on these complaints, specifically regarding care plan compliance and staffing ratios.
Severity Breakdown
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to meet professional standards of quality in comprehensive care plans, including inadequate assessment and monitoring of residents' weights and physician orders. | Level D |
| Failure to maintain required minimum staff-to-resident ratios for Certified Nurse Aides and nursing staff as mandated by New Jersey law. | — |
Report Facts
Census: 103
Sample size: 10
Deficient CNA staffing days: 13
Required CNA staffing: 14
Actual CNA staffing: 8
Required staffing hours: 333.25
Actual staffing hours: 320
Staffing hours difference: -13.25
Inspection Report
Routine
Census: 96
Capacity: 132
Deficiencies: 12
Sep 27, 2024
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health from 09/23/24 through 09/27/24 to assess compliance with long term care facility regulations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B requirements, including an Immediate Jeopardy related to infection control due to failure to properly disinfect multi-use glucometers. Additional deficiencies were noted in respiratory care, nurse staffing information posting, infection prevention and control, mandatory access to care, cooking facilities, fire alarm system maintenance, and life safety code compliance.
Complaint Details
The survey included complaint investigation for multiple complaint numbers (NJ00166884, NJ00170399, NJ00172105, NJ00174237, NJ00177137, NJ00169244, NJ00176606, NJ00162439). The Immediate Jeopardy was identified during the complaint survey related to infection control. The facility submitted a removal plan and corrective actions were validated as completed by 09/27/24.
Severity Breakdown
Immediate Jeopardy: 1
Level D: 1
Level C: 1
Level K: 1
Level A: 1
Level F: 7
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure multi-use glucometers were disinfected with an EPA approved disinfectant between resident use, resulting in Immediate Jeopardy. | Immediate Jeopardy |
| Failure to ensure one resident had appropriate physician orders and proper labeling for respiratory/tracheostomy care and suctioning. | Level D |
| Failure to post nurse staffing data on all floors where residents lived, limiting resident access to staffing information. | Level C |
| Failure to establish and maintain an infection prevention and control program including adequate doffing of PPE and proper disposal of linens. | Level K |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | Level A |
| Failure to ensure cooking facilities were properly separated and exhaust hoods were not damaged, posing potential risk to all 96 residents. | Level F |
| Failure to complete required fire alarm system testing and maintenance in accordance with NFPA standards. | Level F |
| Failure to ensure smoke detection sensitivity testing was completed on smoke detectors. | Level F |
| Failure to ensure smoke barriers were sealed with fire rated material, affecting 96 residents. | Level F |
| Failure to ensure fire doors were inspected annually and fire door tags were legible. | Level F |
| Failure to ensure emergency generator load bank test was completed within required timeframe. | Level F |
| Failure to ensure maintenance and testing of fire doors and electrical systems were performed and documented as required. | Level F |
Report Facts
Survey Census: 96
Total Capacity: 132
Deficiency Counts: 12
Resident Sample Size: 50
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 6
Apr 16, 2024
Visit Reason
Complaint investigation #NJ00171849 conducted due to allegations of noncompliance with federal regulations related to resident care and facility operations.
Findings
The facility was found noncompliant with multiple federal requirements including accuracy of resident assessments, care plan timing and revision, activities of daily living assistance, pain management, and sufficient nursing staff. Specific deficiencies involved inaccurate wound coding in MDS, failure to revise care plans for pain, inadequate assistance with incontinence care, inconsistent pain medication administration, and insufficient staffing levels impacting resident care.
Complaint Details
Complaint #NJ00171849 triggered the investigation. The complaint involved issues with resident care including wound assessment accuracy, pain management, care plan revisions, incontinence care, and staffing adequacy.
Severity Breakdown
SS=D: 3
SS=G: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to accurately encode a resident's wound in Minimum Data Set (MDS) assessment. | SS=D |
| Failed to implement and revise care plan interventions for a resident experiencing pain. | SS=G |
| Failed to provide assistance with activities of daily living, specifically incontinence care. | SS=D |
| Failed to consistently follow pain management policies and administer medications as ordered. | SS=G |
| Failed to ensure adequate nursing staff to meet resident care needs. | SS=D |
| Failed to have a Registered Nurse complete a skin assessment for a resident on a follow-up visit. | — |
Report Facts
Census: 89
Sample size: 3
Staffing: 3
Audit frequency: 5
Audit duration: 4
Audit duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| UM/LPN #1 | Unit Manager/Licensed Practical Nurse | Confirmed wound treatment documentation and miscoding of MDS assessment. |
| MDS Coordinator | MDS Coordinator | Confirmed miscoding of resident wound in MDS assessment. |
| LPN #3 | Licensed Practical Nurse | Provided information about resident pain management and medication administration. |
| CNA #1 | Certified Nursing Assistant | Observed providing care to Resident #2 and reported staffing shortages impacting care. |
| OT/DOR | Occupational Therapist/Director of Rehab | Discussed resident's therapy status and communication with nursing regarding resident condition. |
| COTA | Certified Occupational Therapy Aide | Documented therapy notes and communication with nursing about resident's condition. |
| LPN #4 | Licensed Practical Nurse | Assigned nurse for Resident #1; reported no notification of resident's condition changes. |
| Director of Nursing | Director of Nursing | Oversaw education and auditing related to MDS accuracy, care plans, pain management, and staffing. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Feb 15, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ00171288 to investigate allegations related to failure in implementing a resident's physician order and staffing ratio deficiencies.
Findings
The facility failed to ensure Resident #3 received care according to a physician's order, resulting in Immediate Jeopardy due to a Certified Nursing Assistant providing care to the wrong resident. Additionally, the facility failed to meet required minimum staffing ratios for Certified Nurse Aides (CNAs) on multiple day shifts and one evening shift.
Complaint Details
Complaint #NJ00171288 was substantiated with findings of Immediate Jeopardy related to Resident #3's care and staffing deficiencies. The Immediate Jeopardy was identified on 2/15/24 and was past non-compliance at the time of the survey.
Severity Breakdown
SS=J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure Resident #3 received care as ordered by a physician, including supervision and assistance devices, leading to Immediate Jeopardy. | SS=J |
| Failure to maintain required minimum staffing ratios for CNAs on 28 of 28 day shifts and 1 of 28 evening shifts. | — |
Report Facts
Census: 105
Sample Size: 3
Deficient CNA staffing days: 28
Deficient CNA staffing evening shifts: 1
Required CNAs on day shifts: 10
Actual CNAs on day shifts: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in the finding for providing care to the wrong resident and subsequently suspended and terminated. |
| RN #1 | Registered Nurse | Provided statements regarding the incident and care of Resident #3. |
| Director of Nursing | Director of Nursing (DON) | Provided information about the incident, staffing, and corrective actions. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Documented progress notes related to Resident #3. |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 5
Oct 3, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to medication administration, respiratory care, infection prevention and control, staffing ratios, and fire safety compliance. Specific issues included failure to follow physician orders for medication and treatment, improper respiratory therapy administration, inadequate infection control practices including PPE use and hand hygiene, failure to maintain required staffing ratios, and missing fire safety information on evacuation diagrams.
Severity Breakdown
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to hold medication as per physician's order, inaccurate documentation, and failure to verify physician orders for treatment administration for 2 of 20 residents. | SS=D |
| Failure to ensure respiratory therapy was administered according to physician's orders for 2 of 3 residents reviewed. | SS=D |
| Failure to appropriately don PPE and perform hand hygiene, and failure to provide treatments in accordance with infection control protocols for residents on transmission-based precautions. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
| Failure to identify fire alarm pull stations and fire extinguishers on emergency evacuation diagrams posted throughout the facility. | — |
Report Facts
Census: 55
Sample Size: 17
Deficiencies cited: 2
Deficiencies cited: 2
Staffing ratios non-compliance: 2
Handwashing duration: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Re-educated nurses on medication administration and treatment order review. | |
| Licensed Practical Nurse (LPN) | Assigned to residents with medication administration deficiencies. | |
| Registered Nurse (RN) | Observed performing wound care and treatment administration with infection control deficiencies. | |
| Certified Nurse Aide (CNA) | Observed not following PPE and hand hygiene protocols. | |
| Director of Nursing (DON) | Acknowledged deficiencies and discussed corrective actions. | |
| Licensed Nursing Home Administrator (LNHA) | Informed of deficiencies and corrective plans. |
Inspection Report
Life Safety
Deficiencies: 5
Sep 28, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 09/28 and 09/29/2022 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be noncompliant with several life safety code requirements including emergency lighting failure, stairwell doors not positively latching, inadequate fire sprinkler coverage, improper electrical receptacle protection, and lack of a remote emergency generator stop station.
Severity Breakdown
SS=E: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide a fully functioning battery backup emergency light above the emergency generator. | SS=E |
| Ten of sixteen exit access stairwell doors did not positively latch into their frames to maintain fire rated construction. | SS=F |
| Failed to provide proper fire sprinkler coverage in certain areas including a missing escutcheon cap in the nourishment room and no sprinkler protection in the air handler room. | SS=E |
| One of twelve electrical outlets/power strips next to a water source lacked proper working Ground-Fault Circuit Interrupter (GFCI) protection. | SS=E |
| Failed to ensure a remote manual stop station for the emergency generator was installed; emergency stop was only on the generator control panel. | SS=E |
Report Facts
Fire rated doors not latching: 10
Electrical outlets tested: 12
Electrical outlets failing GFCI: 1
Emergency generator: 1
Inspection Report
Routine
Census: 54
Deficiencies: 0
Oct 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 57
Deficiencies: 0
Aug 31, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Apr 15, 2021
Visit Reason
The inspection was conducted in response to complaint NJ 144656 to assess compliance with long term care facility regulations.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Complaint Details
Complaint NJ 144656 was investigated and the facility was found to be in compliance.
Report Facts
Sample size: 3
Inspection Report
Abbreviated Survey
Census: 61
Deficiencies: 0
Mar 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 18
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Jan 7, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00138404, NJ00138449, and NJ00139553.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ00138404, NJ00138449, and NJ00139553 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 11
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Jan 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Routine
Census: 64
Deficiencies: 0
Dec 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Census: 64
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