Cycle 1
Health 2025-05-27 · Fire 2025-05-27
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
West Orange, NJ
Complete Care At Summit Ridge
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
Facility snapshot
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
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing
LPN hours / resident day
0.87
Licensed practical nurse staffing
Aide hours / resident day
2.32
Nurse aide staffing
Weekend hours
3.33
Weekend nurse staffing
RN turnover
29%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-04 · Fire 2023-04-04
13 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-03-29 · Fire 2021-03-29
2 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-05-27
K223 · Egress Deficiencies
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
F · Potential for more than minimal harm
2025-05-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K321 · Smoke Deficiencies
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
F · Potential for more than minimal harm
2025-05-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K741 · Miscellaneous Deficiencies
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
F · Potential for more than minimal harm
2025-05-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
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
F · Potential for more than minimal harm
2025-05-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-05-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-25
F · Potential for more than minimal harm
2023-04-04
K222 · Egress Deficiencies
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
F · Potential for more than minimal harm
2023-04-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-05-02
F · Potential for more than minimal harm
2023-04-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-04-04
K321 · Smoke Deficiencies
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
F · Potential for more than minimal harm
2023-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-10
F · Potential for more than minimal harm
2023-04-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-25
F · Potential for more than minimal harm
2023-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-25
F · Potential for more than minimal harm
2023-04-04
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-04-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-04-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-06
E · Potential for more than minimal harm
2023-04-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-04-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-04-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-11-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-05-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-27
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-27
F584 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-05-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-27
F755 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2025-05-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-10
F · Potential for more than minimal harm
2023-04-04
F755 · Pharmacy Service Deficiencies
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
E · Potential for more than minimal harm
2023-04-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-04-04
F812 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2023-04-04
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-04-04
F921 · Environmental Deficiencies
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
D · Potential for more than minimal harm
2023-04-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-04-04
F693 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2023-04-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-04-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-04-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-04-04
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-04-04
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-19
D · Potential for more than minimal harm
2021-03-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-04-19
B · Minimal harm
2021-03-29
F921 · Environmental Deficiencies
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
What sits behind the stars
Ownership
Stein, Shalom
5% Or Greater Indirect Ownership Interest · Individual
Eef Capital LLC
5% Or Greater Direct Ownership Interest · Organization
Schlaff, Benny
5% Or Greater Indirect Ownership Interest · Individual
Schlaff, Nachum
5% Or Greater Indirect Ownership Interest · Individual
Agresti, James
Operational/Managerial Control · Individual
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Oleka, Kanene
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Daughters Of Israel Pleasant Valley Home
West Orange, NJ
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Alaris Health At West Orange
West Orange, NJ
3-star overall rating with 2-star inspections with $18,000 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Livingston Post Acute Care
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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