11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
West Orange, NJ
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
20 Summit Street, West Orange, NJ
(973) 736-2000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
152
Certified beds
Average residents
142
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1973-07-01
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
RN hours / resident day
0.56
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
4,758
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9918
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.44
Baseline 20.81% · Performance 20.77% · Measure score 1.44 · Achievement 1.44 · Improvement 0
Healthcare-associated infections
5.53
Baseline 11.50% · Performance 7.57% · Measure score 5.53 · Achievement 0.87 · Improvement 5.53
Total nurse turnover
6.61
Baseline 68.02% · Performance 37.31% · Measure score 6.61 · Achievement 6.45 · Improvement 6.61
Adjusted total nurse staffing
1.91
Baseline 3.77 hours · Performance 3.62 hours · Measure score 1.91 · Achievement 1.91 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.14% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 19.13% · Lower 95% interval 9.32% |
| Discharge to community | 53.03% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 40.22% · Lower 95% interval 44.73% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 83 · Denominator 83 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 83 |
| Discharge self-care score | 71.7% |
53.69%
18 pts better
|
Numerator 38 · Denominator 53 |
| Discharge mobility score | 54.72% |
50.94%
3.8 pts better
|
Numerator 29 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 8.43% |
2.29%
6.1 pts worse
|
Numerator 7 · Denominator 83 · Adjusted rate 5.54% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 4.24% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 161 · Denominator 161 |
| Staff flu vaccination coverage | 96.34% |
42%
54.3 pts better
|
Numerator 158 · Denominator 164 |
| Discharge function score | 66.04% |
56.45%
9.6 pts better
|
Numerator 35 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 55 · Denominator 55 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 19.15% |
25.2%
6.1 pts worse
|
Numerator 9 · Denominator 47 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.1
0.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
93.0%
6 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
2.4%
1.6 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
11.4%
9.5 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 2.4% · Q4 3.3% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.6%
3.3 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.9% · Q3 1.7% · Q4 0.8% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
19.0%
5.6 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 14.2% · Q3 13.4% · Q4 10.7% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
13.5%
10.4 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.5% · Q3 3.5% · Q4 2.5% · 4Q avg 3.1% · 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 | 3.3% |
9.8%
6.5 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.9% · Q3 0.0% · Q4 4.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.2% |
9.7%
7.5 pts better
|
14.9%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.2% · Q3 0.0% · Q4 1.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.8% |
15.9%
3.1 pts better
|
19.8%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 11.8% · Q3 8.1% · Q4 12.5% · 4Q avg 12.8% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
6.0%
2.9 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.5% · Q3 2.6% · Q4 4.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
78.7%
20.2 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 97.9% · Q3 99.3% · Q4 99.1% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
8.2%
0.8 pts worse
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 9.8% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.2%
0.4 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.2% · Q3 1.1% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.1%
19.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
25.4%
2.1 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 24.4% · Expected 25.0% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (4 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-07-07
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-25
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-25
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-06-25
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-25
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-25
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-25
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-25
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-25
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-25
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-25
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-25
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-04-10
Fire Safety
Install proper backup exit lighting.
Corrected 2023-05-02
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-13
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-11
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-10
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-25
Fire Safety
Have an externally vented heating system.
Corrected 2023-04-27
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-06
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-05
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-17
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-05
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-03
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-03
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-10
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-10
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-10
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.
Corrected 2025-06-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-10
Health
Keep all essential equipment working safely.
Corrected 2025-06-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-19
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-12
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-19
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-19
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 2023-04-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-19
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-19
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-04-19
Health
Dispose of garbage and refuse properly.
Corrected 2023-04-12
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-19
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-04-19
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-04-19
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
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Livingston, NJ
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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