Deficiency Index

Complete Care at Summit Ridge

West Orange, New Jersey · CCN 315038

16 surveys since 2010. The first finding at harm level was recorded in 2017.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
80
Surveys
16
Harm or worse
2
Immediate jeopardy
2
The record, 2010–2025
’10’15’20’25
No harm recordedHarm or worseNot surveyed
Immediate jeopardy2

Findings at the most serious level CMS records.

Beyond CMS’s monthly file12/16

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
152
Ownership
For profit - Limited Liability company
Chain
COMPLETE CARE
County
Essex
Medicare-certified since
1973

CMS ratings

Overall
4
Health inspection
3
Staffing
3
Quality measures
5

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded fewer weighted findings than most of its peer group.

Weighted by harm level, against 168 for-profit facilities with 128 or more beds in New Jersey.

Last survey on record

Nov 20, 2025

354 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.563.47
Registered-nurse hours per resident day0.52—
Annual nurse turnover38.8%41.8%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD2076.9%E415.4%F13.8%
No harm, potential for minimalA—B13.8%C—
CMS’s current file: 26 of the 80 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6582×

    Ensure services provided by the nursing facility meet professional standards of quality.

  • F6952×

    Provide safe and appropriate respiratory care for a resident when needed.

  • F7552×

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • F8802×

    Provide and implement an infection prevention and control program.

  • F9212×

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

In the surveyor’s words

From the most serious findings on record at Complete Care at Summit Ridge, in the surveyor’s own words.

  • No harm, potential for more than minimal, widespreadF755Apr 4, 2023

    45449 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a) dispensed and administered controlled substance (narcotic) medication was accurately accounted for (Resident #2, #12, #31, #78, and #120), b) discontinued medications were removed from active inventory (Resident #122 and #46), which was identified separately in two (2) of six (6) medication carts, c) medications were not pre-poured for more than one medication pass, medications were secured within the medication cart (Resident #78 and #12), d) medications were destroyed after resident refusal (Resident #12) e) accurate accounting of Resident #12's dispensed… […]

  • No harm, potential for more than minimal, patternF658Apr 4, 2023

    Complaint # NJ00154046 Based on observation, interview, record review, and review of the facility provided pertinent documents, it was determined that the facility failed to: a) follow through with dental recommendation for a total of eleven (11) months for one (1) of four (4)residents, (Resident#80) reviewed for dental concerns; b) follow the physician's order with regard to blood pressure medications with parameters for one (1) of twenty nine (29) residents, (Resident#24) reviewed for medications; and, c) ensure that resident's weight was obtained and recorded according to the facility's procedure for one (1) of six (6), (Resident#295) reviewed for weights according to the standards of clinical practice. […]

  • No harm, potential for more than minimal, patternF812Apr 4, 2023

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) consistently monitor refrigerator and freezer temperatures and document them in the facility logs and b) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a foodborne illness. This deficient practice was evidenced by the following: On 3/10/22 at 9:59 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In walk-in refrigerator#1, the surveyor observed one of five pitchers of iced tea with a use-by date of 3/05. The pitcher was half full. The FSD stated that it should have been discarded on the use-by date. 2. […]

  • No harm, potential for more than minimal, patternF886Apr 4, 2023

    Based on the interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to conduct COVID-19 testing for two (2) of two (2) residents (Residents#132 and #39) and 16 of 16 staff identified as close contacts following a staff member testing positive for COVID-19 in accordance with the facility's policies and Centers for Disease Control and Prevention (CDC) guidelines for infection control and to mitigate the spread of COVID-19 (a deadly, highly transmissible infectious disease). […]

  • No harm, potential for more than minimal, patternF921Apr 4, 2023

    Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff for two (2) of two (2) facility areas observed for an environmental tour (laundry area and resident rooms) according to facility and standard of clinical practice. This deficient practice was evidenced by the following: On 3/16/23 at 11:49 AM, the surveyor toured the laundry area in the presence of the Laundry Service Director (LSD). The surveyor observed a commercial size trash can in the middle of the laundry room dryer area. The depth of water collection in the commercial trash can was approximately 5 (five) inches deep. […]

Read 22 findings in full →The most serious and the most recent: 22 of 80 on record.

Every survey on record

FindingsAt actual harm or above

  • Nov 20, 2025Complaint3 findings
  • May 27, 2025Standard8 findings
  • Apr 4, 2023Standard13 findings
  • Mar 29, 2021Standard2 findings
  • Jul 22, 2019Complaint1 finding
  • May 17, 2019Standard3 findings
  • Jun 14, 2018Standard3 findings
  • Jun 14, 2017Complaint2 findings · 2 harm
Show the 8 earlier surveys
  • Apr 24, 2017Standard10 findings
  • Mar 11, 2016Standard9 findings
  • Jan 22, 2015Standard and complaint6 findings
  • Feb 26, 2014Standard3 findings
  • Jan 9, 2013—9 findings
  • Oct 15, 2012—1 finding
  • Nov 3, 2011—2 findings
  • Sep 28, 2010—5 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction