Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Summit Ridge during CMS and state inspections, most recent first.
A resident's representative reported to the facility's social worker that a staff member told the resident to "shut up." The facility did not report this verbal abuse allegation to the Department of Health, as required by policy, because the resident denied the incident and was cognitively intact. There was no evidence of a full investigation or proper notification to authorities.
A resident with paraplegia and other complex medical needs, who required maximal assistance with toileting hygiene, did not have documented evidence of incontinence care being provided on multiple shifts. Staff interviews revealed inconsistent use of documentation codes, and the facility's records showed 'not attempted' for toileting hygiene on the dates in question, despite the resident's complaints about delayed care.
A resident with paraplegia and other medical conditions developed a stage 2 pressure ulcer, but there was no evidence that a physician's order for wound care was entered or that wound care was provided and documented for two days after the wound was discovered. Interviews confirmed that wound care orders were not initiated or documented as required by facility policy.
Failure to Report Alleged Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with paraplegia, spinal stenosis, and diabetes, who was cognitively intact as indicated by a perfect BIMS score. The resident's representative reported to the facility's social worker that a staff member told the resident to "shut up." The resident was unsure of the staff member's name, and the representative could not recall the exact date the incident was reported to the social worker. Despite this, the facility did not report the allegation to the Department of Health (DOH) as required. During interviews, the Licensed Nursing Home Administrator stated that the allegation was not reported to the DOH because the resident denied that verbal abuse had occurred and was cognitively intact. The administrator also indicated that staff interviews did not substantiate the claim. However, there was no evidence that the facility fully investigated the allegation or notified the DOH as mandated by facility policy, which requires immediate reporting of all alleged violations and follow-up with government agencies.
Failure to Document and Provide Required Toileting Hygiene Assistance
Penalty
Summary
A deficiency was identified when the facility failed to provide documented evidence that care and assistance with activities of daily living, specifically toileting hygiene, was provided to a resident who required maximal assistance. The resident, who had diagnoses including paraplegia, spinal stenosis, and diabetes, was assessed as needing substantial and maximal assistance with toileting hygiene and was frequently incontinent. Documentation for two specific dates showed 'NA' (not attempted) for toileting hygiene on both day and evening shifts, and there were no progress notes indicating that incontinence care was provided on those dates. The resident had also filed grievances regarding delays in incontinence care. Interviews with staff revealed inconsistent understanding and use of the 'NA' code in documentation, with one CNA stating that 'NA' was used if the resident did not have a bowel movement, while facility policy indicated 'NA' meant not attempted. The Infection Preventionist confirmed that ADL documentation should be completed every shift to ensure care was given, but could not confirm whether care was provided on the dates in question. The lack of documentation and conflicting explanations from staff led to the finding that the facility did not ensure proper care and assistance for the resident's toileting hygiene needs.
Failure to Timely Initiate and Document Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to provide evidence that a physician's order for wound care was carried out and documented for two days to treat a facility-acquired pressure injury. A resident with paraplegia, spinal stenosis, and diabetes was noted to have an opening on the sacrum during care. Documentation showed that the nurse cleansed the wound, applied medical honey, and notified the physician and family. However, there was no evidence in the Order Summary Report or Treatment Administration Record that a physician's order for wound care was entered or that wound care was provided on the two days following the discovery of the wound. The wound assessment indicated a stage 2 pressure ulcer on the coccyx, acquired in-house, with specific treatment orders documented only after a two-day delay. Interviews with the ADON and LPN confirmed that the wound care order was not initiated or entered into the computer until two days after the wound was discovered, despite facility policy requiring prompt documentation and implementation of treatment orders. Facility policies also required that all treatments be documented in the medical record, which was not done in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Daughters Of Israel Pleasant Valley Home | 0.4 mi | ★★★★★ | 22 | 0 |
| Alaris Health At West Orange | 1.1 mi | ★★★★★ | 1 | 0 |
| Livingston Post Acute Care | 1.6 mi | ★★★★★ | 21 | 0 |
| Stratford Manor Rehabilitation And Care Center | 1.6 mi | ★★★★★ | 10 | 0 |
| Inglemoor Rehabilitation And Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.