D+
52/100COMPLETE CARE AT PROSPECT HEIGHTS LLC Inspection Report, Violations & Safety Grade (HACKENSACK, New Jersey)
336 PROSPECT AVE, HACKENSACK, New Jersey 07601
Phone: 2016781800
CMS Overall:2/5
Overview & Bed Count
Certified Beds
196
Avg Residents/Day
131.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Bergen
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health1/5
Staffing2/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | New Jersey Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.85 | 0.70 | +0.15 |
| Total Nurse Hours per Resident per Day | 2.79 | 3.90 | -1.11 |
| CMS Staffing Rating | 2/5 | 3.2/5 | - |
| Nursing Staff Turnover | 47.2% | 39.3% | - |
Health Citation History
33 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-29 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2026-01-29 | Administration Deficiencies | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | F – Moderate Harm Potential |
| 2026-01-29 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E – Moderate Harm Potential |
| 2026-01-29 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2026-01-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2026-01-29 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | D – Moderate Harm Potential |
| 2026-01-29 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2026-01-29 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2026-01-29 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2026-01-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-01-29 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2026-01-29 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2026-01-29 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-01-29 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | D – Moderate Harm Potential |
| 2026-01-29 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | D – Moderate Harm Potential |
| 2026-01-29 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2026-01-29 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2026-01-29 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2026-01-29 | Environmental Deficiencies | Keep all essential equipment working safely. | D – Moderate Harm Potential |
| 2025-03-05 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-02-11 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-09-27 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-09-27 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-09-27 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | C – Minimal Harm Potential |
| 2024-04-16 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | G – Actual Harm |
| 2024-04-16 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | G – Actual Harm |
| 2024-04-16 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-04-16 | Quality of Life and Care Deficiencies | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D – Moderate Harm Potential |
| 2024-04-16 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | D – Moderate Harm Potential |
| 2024-02-15 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2022-10-03 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2022-10-03 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2022-10-03 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
12 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-29 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-01-29 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2024-09-27 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2024-09-27 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-09-27 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2024-09-27 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2024-09-27 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2022-10-03 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2022-10-03 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | E – Moderate Harm Potential |
| 2022-10-03 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2022-10-03 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | E – Moderate Harm Potential |
| 2022-10-03 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
Total Penalties & Fines
$59,312
Total Fine Amount (CMS)
6
Number of Fines
6
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-04-16 | Fine | $25,300 | - |
| 2024-02-20 | Fine | $3,798 | - |
| 2024-02-15 | Fine | $15,646 | - |
| 2024-02-12 | Fine | $3,418 | - |
| 2024-01-22 | Fine | $7,976 | - |
| 2023-12-18 | Fine | $3,174 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the HACKENSACK area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.