Cycle 1
Health 2024-09-27 · Fire 2024-09-27
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Hackensack, NJ
Complete Care At Prospect Heights LLC
2-star overall rating with 1-star inspections with $118,483 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
336 Prospect Ave, Hackensack, NJ
(201) 678-1800
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
196
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
2000-01-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.44
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
2.81
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,300
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 23.14% · Performance 24.47% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.64
Baseline 9.21% · Performance 8.31% · Measure score 1.64 · Achievement 0 · Improvement 1.64
Total nurse turnover
4.32
Baseline 36.73% · Performance 46.02% · Measure score 4.32 · Achievement 4.32 · Improvement 0
Adjusted total nurse staffing
2.38
Baseline 4.84 hours · Performance 3.75 hours · Measure score 2.38 · Achievement 2.38 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.14% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 416 · Observed rate 13.22% · Lower 95% interval 9.3% |
| Discharge to community | 56.99% |
50.57%
6.4 pts better
|
Better than the National Rate · Eligible stays 489 · Observed rate 46.83% · Lower 95% interval 52.07% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.58% |
95.27%
3.3 pts better
|
Numerator 278 · Denominator 282 |
| Falls with major injury | 0.35% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 282 |
| Discharge self-care score | 60.31% |
53.69%
6.6 pts better
|
Numerator 79 · Denominator 131 |
| Discharge mobility score | 61.07% |
50.94%
10.1 pts better
|
Numerator 80 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 1.42% |
2.29%
0.9 pts better
|
Numerator 4 · Denominator 281 · Adjusted rate 1.24% |
| Healthcare-associated infections requiring hospitalization | 8.31% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 322 · Observed rate 10.87% · Lower 95% interval 6.22% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 177 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 150 · Denominator 150 |
| Discharge function score | 63.36% |
56.45%
6.9 pts better
|
Numerator 83 · Denominator 131 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 154 · Denominator 154 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 98 · Denominator 100 |
| Resident COVID-19 vaccinations up to date | 2.27% |
25.2%
22.9 pts worse
|
Numerator 3 · Denominator 132 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 4.4 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.1
About the same
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
93.0%
2.5 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 96.6% · Q3 93.3% · Q4 95.7% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
97.2%
0.2 pts worse
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
2.4%
2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.1% |
11.4%
0.7 pts worse
|
11.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 12.2% · Q3 11.8% · Q4 18.2% · 4Q avg 12.1% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
4.6%
1.9 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 1.7% · Q4 4.5% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
19.0%
5.4 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 14.3% · Q3 8.3% · Q4 18.8% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
13.5%
6.7 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 7.3% · Q3 6.8% · Q4 4.3% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.4% |
9.8%
1.6 pts worse
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 4.6% · Q3 8.5% · Q4 16.4% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
9.7%
8.1 pts worse
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.1% · Q3 11.5% · Q4 19.7% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
15.9%
8.8 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 33.8% · Q3 17.1% · Q4 22.8% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.0%
5.3 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 15.5% · Q3 6.1% · Q4 7.1% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
78.7%
13.7 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 93.9% · Q3 85.5% · Q4 91.4% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
8.2%
2.2 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.5% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 1.6% · Q4 1.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
80.1%
7.1 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
25.4%
1.5 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 28.0% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-03 · Fire 2022-10-03
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2020-02-25 · Fire 2020-02-25
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-09-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-02
F · Potential for more than minimal harm
2024-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-31
F · Potential for more than minimal harm
2022-10-03
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-11-22
E · Potential for more than minimal harm
2022-10-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-22
E · Potential for more than minimal harm
2022-10-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-10-03
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-11-22
E · Potential for more than minimal harm
2022-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-29
F584 · Resident Rights Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Not marked corrected
D · Potential for more than minimal harm
2025-03-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-12
K · Immediate jeopardy
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-07
C · Minimal harm
2024-09-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-07
G · Actual harm
2024-04-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-08
G · Actual harm
2024-04-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-08
J · Immediate jeopardy
2024-02-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-11
D · Potential for more than minimal harm
2022-10-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-14
E · Potential for more than minimal harm
2020-02-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-03-20
E · Potential for more than minimal harm
2020-02-25
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2020-03-20
Penalties and ownership
What sits behind the stars
$59,171
2024-09-27
Fine
Fine · fine $59,171
Fine
$25,300
2024-04-16
Fine
Fine · fine $25,300
Fine
$3,798
2024-02-20
Fine
Fine · fine $3,798
Fine
$15,646
2024-02-15
Fine
Fine · fine $15,646
Fine
$3,418
2024-02-12
Fine
Fine · fine $3,418
Fine
$7,976
2024-01-22
Fine
Fine · fine $7,976
Fine
$3,174
2023-12-18
Fine
Fine · fine $3,174
Fine
Ownership
Pc Hmh Opco Holdings 2 LLC
5% Or Greater Direct Ownership Interest · Organization
Aspril, Vilma
Operational/Managerial Control · Individual
Pc Hmh Holdings 2 LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Careone At Wellington
Hackensack, NJ
3-star overall rating with 2-star inspections with $18,431 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Atlas Rehabilitation And Healthcare At Maywood
Maywood, NJ
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Complete Care At Regent LLC
Hackensack, NJ
2-star overall rating with 2-star inspections with 17 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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