Inspection Reports for
Complete Care At Summit Ridge
20 Summit Street, West Orange, NJ, 07052
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
93% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 20, 2025
Visit Reason
The inspection was conducted based on complaint #2661084 involving allegations of verbal abuse, failure to provide adequate toileting hygiene care, and inadequate wound care for Resident #3.
Complaint Details
Complaint #2661084 involved allegations of verbal abuse, inadequate toileting hygiene care, and failure to provide wound care treatment. The verbal abuse allegation was not reported to the Department of Health as required. The facility failed to provide evidence of toileting hygiene care on 11/2/2025 and 11/9/2025. Wound care orders were not initiated until 11/6/2025 despite a wound being noted on 11/4/2025.
Findings
The facility failed to timely report a verbal abuse allegation to the Department of Health, failed to provide documented evidence of toileting hygiene care for Resident #3 on specified dates, and failed to provide and document wound care treatment orders for a pressure ulcer for two days as required.
Deficiencies (3)
Failed to timely report suspected verbal abuse allegation to proper authorities.
Failed to provide documented evidence of toileting hygiene care for a resident requiring maximal assistance.
Failed to provide and document physician's wound care orders and treatment for a facility-acquired pressure ulcer for two days.
Report Facts
Deficiencies cited: 3
Wound measurements: 2.7
Wound measurements: 1
Wound measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding wound care incident report and physician notification |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about wound care orders and treatment documentation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding toileting hygiene care and documentation |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed about verbal abuse allegation reporting |
Notice
Deficiencies: 0
Date: 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
Annual Inspection
Deficiencies: 9
Date: May 22, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity, call bell accessibility, living environment cleanliness, respiratory care, medication administration and control, infection prevention, and maintenance of essential equipment. Deficiencies were generally of minimal harm but affected a few residents.
Deficiencies (9)
Failure to maintain resident dignity during meal service and wound treatment.
Failure to keep call bell within reach of resident requiring assistance.
Failure to post prior year's state inspection results in an accessible area for residents.
Failure to maintain residents' living environment in a clean, sanitary, and homelike manner.
Failure to provide oxygen therapy according to physician's order for a resident.
Failure to provide pharmaceutical services ensuring accurate medication administration and narcotic accountability.
Failure to provide a sanitary environment preventing infection transmission, including improper wound care and IV bag labeling.
Failure to keep oxygen tubing dated and stored properly when not in use.
Failure to maintain essential equipment including air conditioner, grab bars, and heat register in resident rooms.
Report Facts
Residents reviewed: 29
Medication errors: 1
Narcotic discrepancies: 4
Oxygen flow rate: 3
BIMS scores: 0
BIMS scores: 9
Number of medication forms reviewed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Involved in dignity issue with clothing protector during meal service | |
| Licensed Practical Nurse | Applied medication dressing incorrectly and did not disinfect overbed table during wound care | |
| Registered Nurse/Unit Manager | Confirmed oxygen flow rate error and improper oxygen tubing storage | |
| Director of Maintenance | Acknowledged failure to inspect and maintain resident room equipment | |
| Regional Registered Nurse | Acknowledged medication administration and narcotic inventory errors | |
| Licensed Nursing Home Administrator | Discussed findings and concerns with surveyor | |
| Director of Nursing | Discussed findings and concerns with surveyor |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Date: Apr 4, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint #'s NJ00152736, NJ00154046, NJ00154073, NJ00154662, NJ00156473 were investigated during this recertification survey.
Findings
Deficiencies were cited related to professional standards of care, accident hazards, medication management, food safety, infection control, and life safety code compliance.
Deficiencies (23)
Failed to meet professional standards of quality in resident care plans and medication orders.
Failed to ensure resident environment free of accident hazards and provide adequate supervision to prevent accidents.
Failed to provide appropriate treatment and services for residents fed by enteral means.
Failed to provide pharmaceutical services in accordance with professional standards including medication administration and record keeping.
Medication error rate exceeded 5% during observed medication passes.
Failed to ensure food served was at safe and appetizing temperatures.
Failed to provide food in the correct consistency according to physician's order.
Failed to maintain refrigerator and freezer temperatures and maintain kitchen environment and equipment in a sanitary manner.
Failed to properly dispose of garbage and maintain dumpster areas clean.
Failed to perform hand hygiene and properly use PPE by staff in accordance with CDC guidelines and facility policy.
Failed to conduct COVID-19 testing for residents and staff identified as close contacts following a positive staff member.
Failed to provide a safe, sanitary, and comfortable environment including water leaks in laundry area and unclean resident bathrooms.
Failed to inspect fire doors annually in accordance with NFPA standards.
Delayed egress doors not labeled or alarm not functioning properly.
Failed to provide emergency illumination that operates automatically along means of egress.
Failed to provide exit signs showing direction of travel where direction to nearest exit was not apparent.
Failed to ensure hazardous areas were protected by self-closing fire-rated doors and smoke resisting partitions.
Failed to provide combustion air from outside to fuel fired HVAC units.
Failed to conduct fire drills with varying activation types and simulation of specific emergency fire conditions.
One electrical outlet near water source was not equipped with required GFCI protection.
Failed to store oxygen cylinders properly secured against tipping, rupture and damage.
Failed to provide complete sprinkler coverage in elevator room and men's restroom.
Failed to conduct 5-year internal obstruction inspection of sprinkler system and missing wrench in sprinkler cabinet.
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
Deficiencies: 4
Date: Apr 4, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to follow dental recommendations, medication administration errors related to blood pressure medications, and failure to obtain and record resident weights according to facility procedures.
Complaint Details
Complaint # NJ00154046 and Complaint # NJ00152736. The complaints involved failure to follow dental recommendations, medication administration errors, failure to obtain weights, and unsafe food temperatures. The deficiencies were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to follow through with a dental recommendation for one resident for 11 months, did not follow physician's orders for PRN blood pressure medication for one resident on multiple occasions, and failed to obtain and record weights for a resident as required. Additionally, the facility failed to ensure food and drink were served at safe and appetizing temperatures during meal service.
Deficiencies (4)
Failure to follow through with dental recommendation for one resident for 11 months.
Failure to follow physician's order for PRN Clonidine medication for blood pressure for one resident on multiple dates when SBP was above 160.
Failure to obtain and record resident's weight according to facility procedure for one resident.
Failure to ensure food and drink were served at safe and appetizing temperatures for two residents during meal service.
Report Facts
Residents reviewed for dental concerns: 4
Residents reviewed for medications: 29
Residents reviewed for weights: 6
Food temperatures measured: 14
BIMS score: 6
BIMS score: 15
Weight recorded: 137.6
Blood pressure readings above 160: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietician | Interviewed about weight monitoring responsibilities and procedures. | |
| Director of Nursing (DON) | Interviewed regarding weight monitoring procedures and medication policies. | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed about dental recommendation procedures and documentation. | |
| Licensed Practical Nurse (LPN) | Acknowledged failure to administer PRN Clonidine medication as ordered. | |
| Food Service Director (FSD) | Interviewed about food temperature issues during meal service. | |
| Licensed Nursing Home Administrator (LNHA) | Informed about dental recommendation documentation issues. | |
| Regional Clinical Supervisor (RCS) | Informed about dental recommendation documentation issues. |
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 15
Date: Apr 4, 2023
Visit Reason
The inspection was conducted based on complaint investigations regarding dental care, medication administration, weight monitoring, fall prevention, feeding tube care, respiratory care, pharmaceutical services, medication error rates, food safety and consistency, infection prevention and control, COVID-19 testing, and environmental safety.
Complaint Details
Complaint # NJ00154046 and NJ00152736 involved issues with dental care, medication administration, weight monitoring, fall prevention, feeding tube care, respiratory care, pharmaceutical services, medication error rates, food safety and consistency, infection prevention and control, COVID-19 testing, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to follow dental recommendations, medication administration errors, failure to obtain and document resident weights, inadequate fall prevention measures, improper feeding tube management, lack of respiratory care orders and plans, pharmaceutical service deficiencies including narcotic accountability, medication administration errors exceeding 5%, food temperature and consistency issues, poor infection control practices including hand hygiene and PPE use, incomplete COVID-19 testing of exposed residents and staff, and environmental safety concerns such as leaks and unsanitary conditions.
Deficiencies (15)
Failure to follow dental recommendations for 11 months for one resident.
Failure to follow physician's order for blood pressure medication administration for one resident.
Failure to obtain and document resident weights according to facility policy for one resident.
Failure to maintain fall prevention interventions including proper placement of bilateral floor mats for one resident.
Failure to administer tube feeding per physician's order, document total volume, and properly label feeding tube bags for one resident.
Failure to provide respiratory care with appropriate orders and care plan for one resident on oxygen.
Pharmaceutical service deficiencies including inaccurate narcotic medication accountability, failure to remove discontinued medications, unsecured medications, and expired narcotics in backup machine.
Medication administration errors observed with a 6.9% error rate including wrong eye for eye drops and incorrect dosage of seizure medication.
Failure to maintain safe and appetizing food temperatures during meal service on two nursing units.
Failure to provide correct consistency of diet according to physician's order for one resident.
Failure to consistently monitor and document refrigerator and freezer temperatures and maintain kitchen environment and equipment in sanitary condition.
Failure to properly dispose of and maintain waste in garbage dumpster areas, including trash on floor and open lids.
Failure to perform appropriate hand hygiene and PPE use by staff including Certified Nursing Aide and Housekeeper in accordance with CDC guidelines and facility policy.
Failure to conduct COVID-19 testing for identified close contact residents and staff following a positive staff case according to facility policy and CDC guidelines.
Failure to provide a safe, sanitary, and comfortable environment including unresolved water leak in laundry area and unsanitary conditions in resident bathrooms.
Report Facts
Residents present: 147
Medication error rate: 6.9
Food temperatures: 142.2
Food temperatures: 124
Food temperatures: 122.4
Food temperatures: 109.9
Food temperatures: 59
Food temperatures: 151.1
Food temperatures: 136.6
Food temperatures: 124.6
Food temperatures: 114
Food temperatures: 66
Food temperatures: 73
Expired narcotic tablets: 9
Narcotic medication count discrepancy: 1
Narcotic medication count discrepancy: 1
Narcotic medication count discrepancy: 1
Narcotic medication count discrepancy: 1
Narcotic medication count discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered Oxycodone/Acetaminophen without signing inventory log |
| RN #2 | Registered Nurse | Left unlabeled crushed medications on medication cart and refused education signature |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Observed narcotic medication discrepancies and provided education |
| Dietician #1 | Dietician | Tested positive for COVID-19 and was source of contact tracing |
| CNA | Certified Nursing Aide | Failed to perform hand hygiene and proper PPE use |
| HK | Housekeeper | Failed to perform hand hygiene and proper PPE use |
| DON | Director of Nursing | Provided multiple clarifications and responses regarding deficiencies |
| LNHA | Licensed Nursing Home Administrator | Involved in follow-up and interviews regarding deficiencies |
| RCS | Regional Clinical Supervisor | Involved in follow-up and interviews regarding deficiencies |
| FSD | Food Service Director | Observed food temperature issues and kitchen sanitation concerns |
| DC | Dietary Coordinator | Acknowledged kitchen sanitation and temperature log deficiencies |
| LSD | Laundry Service Director | Reported ongoing leak in laundry area |
| MP | Maintenance Personnel | Confirmed cause of leak in laundry area |
| RLNHA | Regional Licensed Nursing Home Administrator | Discussed diet consistency process and environmental concerns |
| DoR | Director of Rehab | Provided information on diet consistency for resident |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 0
Date: 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.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance with no deficiencies cited.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 97
Deficiencies: 0
Date: 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
Routine
Deficiencies: 2
Date: Mar 29, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care and to evaluate the safety and sanitary conditions of the facility environment.
Findings
The facility failed to accurately follow the physician's oxygen orders for one resident, administering oxygen at 3L/min instead of the ordered 2L/min. Additionally, the facility's basement storage rooms had stained, water-logged, and missing ceiling tiles with an unidentified brown substance, posing a physical environment safety concern.
Deficiencies (2)
Failure to accurately follow physician's orders for oxygen administration for Resident #44, oxygen set at 3L/min instead of ordered 2L/min.
Facility failed to provide a safe and sanitary physical environment; basement storage rooms had stained, water-logged, sagging, and missing ceiling tiles with an unidentified brown substance.
Report Facts
Oxygen rate ordered: 2
Oxygen rate administered: 3
Number of storage rooms inspected: 5
Number of stained ceiling tiles per storage room: 2
Number of missing ceiling tiles per storage room: 4
Inspection Report
Annual Inspection
Census: 97
Deficiencies: 2
Date: 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.
Deficiencies (2)
Facility failed to accurately follow the physician's orders for oxygen administration for Resident #44.
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.
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
Date: 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
Date: 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
Date: Dec 23, 2020
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ 00141996.
Complaint Details
Complaint #: NJ 00141996; The facility was found to be in substantial compliance.
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.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ00138124.
Complaint Details
Complaint #: NJ00138124; the survey was complaint-related and the facility was found compliant.
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.
Report Facts
Sample Size: 7
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