Inspection Reports for Complete Care At Summit Ridge
20 Summit Street, NJ, 07052
Back to Facility ProfileDeficiencies per Year
24
18
12
6
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, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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: 141
Deficiencies: 1
Aug 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint numbers NJ00160705, NJ00164662, and NJ00166717 to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations due to failure to maintain the required minimum staff-to-resident ratios for Certified Nursing Assistants (CNAs) on 14 of 14 day shifts reviewed.
Complaint Details
The complaint investigation was based on three complaint numbers: NJ00160705, NJ00164662, and NJ00166717. The facility was found to be in substantial compliance with federal requirements but deficient in state staffing requirements.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 14 of 14 day shifts. |
Report Facts
Census: 141
Deficient CNA staffing days: 14
Required CNAs per day shift: 18
Actual CNAs per day shift: Ranged from 14 to 17 CNAs on various days, all below the required 18.
Inspection Report
Annual Inspection
Census: 147
Capacity: 152
Deficiencies: 23
Apr 4, 2023
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 professional standards of care, accident hazards, medication management, food safety, infection control, and life safety code compliance.
Complaint Details
Complaint #'s NJ00152736, NJ00154046, NJ00154073, NJ00154662, NJ00156473 were investigated during this recertification survey.
Severity Breakdown
SS=E: 11
SS=D: 4
SS=F: 8
Deficiencies (23)
| Description | Severity |
|---|---|
| Failed to meet professional standards of quality in resident care plans and medication orders. | SS=E |
| Failed to ensure resident environment free of accident hazards and provide adequate supervision to prevent accidents. | SS=D |
| Failed to provide appropriate treatment and services for residents fed by enteral means. | SS=D |
| Failed to provide pharmaceutical services in accordance with professional standards including medication administration and record keeping. | SS=F |
| Medication error rate exceeded 5% during observed medication passes. | SS=D |
| Failed to ensure food served was at safe and appetizing temperatures. | SS=D |
| Failed to provide food in the correct consistency according to physician's order. | SS=D |
| Failed to maintain refrigerator and freezer temperatures and maintain kitchen environment and equipment in a sanitary manner. | SS=E |
| Failed to properly dispose of garbage and maintain dumpster areas clean. | SS=D |
| Failed to perform hand hygiene and properly use PPE by staff in accordance with CDC guidelines and facility policy. | SS=D |
| Failed to conduct COVID-19 testing for residents and staff identified as close contacts following a positive staff member. | SS=E |
| Failed to provide a safe, sanitary, and comfortable environment including water leaks in laundry area and unclean resident bathrooms. | SS=E |
| Failed to inspect fire doors annually in accordance with NFPA standards. | SS=E |
| Delayed egress doors not labeled or alarm not functioning properly. | SS=E |
| Failed to provide emergency illumination that operates automatically along means of egress. | SS=F |
| Failed to provide exit signs showing direction of travel where direction to nearest exit was not apparent. | SS=F |
| Failed to ensure hazardous areas were protected by self-closing fire-rated doors and smoke resisting partitions. | SS=F |
| Failed to provide combustion air from outside to fuel fired HVAC units. | SS=F |
| Failed to conduct fire drills with varying activation types and simulation of specific emergency fire conditions. | SS=F |
| One electrical outlet near water source was not equipped with required GFCI protection. | SS=D |
| Failed to store oxygen cylinders properly secured against tipping, rupture and damage. | SS=F |
| Failed to provide complete sprinkler coverage in elevator room and men's restroom. | SS=F |
| Failed to conduct 5-year internal obstruction inspection of sprinkler system and missing wrench in sprinkler cabinet. | SS=F |
Report Facts
Census: 147
Total Capacity: 152
Medication error rate: 6.9
Deficient CNA staffing days: 14
Required CNA staffing: 18
Actual CNA staffing: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in medication and infection control findings | |
| Maintenance Director | Named in fire safety, sprinkler, and environmental findings | |
| Regional Facilities Manager | Named in fire safety and environmental findings | |
| Administrator | Named in multiple findings and exit conferences | |
| Infection Control Preventionist Nurse | Named in infection control findings | |
| Licensed Practical Nurse/Unit Manager | Named in infection control and medication findings | |
| Certified Nursing Assistant | Named in infection control and accident hazard findings | |
| Food Service Director | Named in food safety and sanitation findings |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 0
Feb 17, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance with no deficiencies cited.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 97
Deficiencies: 0
Apr 20, 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: 3
Inspection Report
Annual Inspection
Census: 97
Deficiencies: 2
Mar 29, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. A COVID-19 Focused Infection Control Survey was conducted in conjunction with the recertification survey.
Findings
Deficiencies were cited related to failure to accurately follow physician's orders for oxygen administration for one resident, and failure to provide a safe and sanitary physical environment due to stained and missing ceiling tiles in storage rooms in the basement.
Severity Breakdown
SS=D: 1
SS=B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to accurately follow the physician's orders for oxygen administration for Resident #44. | SS=D |
| Facility failed to provide a safe and sanitary physical environment as evidenced by stained, water-logged, sagging, and missing ceiling tiles in storage rooms in the basement. | SS=B |
Report Facts
Sample size: 20
Audit frequency: 4
Audit frequency: 2
Maintenance rounds: 3
Maintenance rounds: 3
Number of storage rooms observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Verified oxygen administration rate for Resident #44 in presence of surveyor | |
| Director of Nursing (DON) | Acknowledged oxygen was not administered according to physician's order and provided re-education to licensed nurses | |
| Administrator | Interviewed regarding oxygen administration and ceiling tile issues | |
| Maintenance Director | Interviewed regarding ceiling tile issues and responsible for replacement and monitoring |
Inspection Report
Life Safety
Deficiencies: 0
Mar 29, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Routine
Census: 91
Deficiencies: 0
Jan 13, 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
Complaint Investigation
Census: 97
Deficiencies: 0
Dec 23, 2020
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ 00141996.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #: NJ 00141996; The facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Dec 15, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ00138124.
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 #: NJ00138124; the survey was complaint-related and the facility was found compliant.
Report Facts
Sample Size: 7
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