Complete Care at Summit Ridge

Inspectors wroteComplaint #: 2661084Based on interviews, medical record review, and review of other pertinent facility documentation on 11/17/2025 and 11/20/2025, it was determined that the facility failed to report a verbal abuse allegation that a resident's representative (RR) reported to the facility's staff and to the Department of Health (DOH) for 1 of 3 residents reviewed for abuse. The deficient practice was identified for 1 of 3 residents reviewed (Resident #3) and was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. [...]

Inspectors wroteComplaint: 2661084Based on interviews, medical record review, and review of other pertinent facility documents on 11/17/2025 and 11/20/2025, it was determined that the facility failed to provide documented evidence that care was provided to a resident who required maximal assistance for toileting hygiene. This deficient practice occurred for 1 of 3 residents (Resident #3) reviewed. The deficient practice was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. [...]

Inspectors wroteComplaint #: 2661084Based on interviews, medical record review, and review of other pertinent facility documents on 11/17/2025 and 11/20/2025, it was determined that the facility failed 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 in accordance with professional standards. This deficient practice occurred for 1 of 3 residents reviewed for wound. The deficient practice was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain the dignity of 2 unsampled residents during the lunchtime meal in the main dining room and 1 sampled resident (#53) during a wound treatment observation. The deficient practice was evidenced by the following. 1. The surveyor observed the lunchtime meal in the main dining room on 05/22/25 at 12:23 PM. The surveyor observed as a Certified Nursing Assistant (CNA) placed a disposable clothing protector on a cognitively impaired resident. The CNA did not explain the procedure of placing the clothing protector prior to attempting to fit it over the resident's head. The clothing protector had a opening where it would be fitted over the resident's head. The opening was too small for the resident's head and got stuck with the clothing protector covering the resident's head and face. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 29 residents reviewed for accommodation of needs (Resident #57), and was evidenced by the following: On 5/22/25 at 12:37 PM, the surveyor observed Resident # 57 seated in a wheelchair with his/her overbed table and lunch tray positioned in front of them. The surveyor observed that the resident's call bell (a bell used to summon staff for assistance) was in the middle of the bed not within the resident's reach. The surveyor reviewed the medical record for Resident #57. A review of the admission Record reflected that Resident #57 was admitted to the facility with diagnoses that included but were not limited to; Diabetes Mellitus, Schizophrenia and Leukocytosis. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to post the prior year's State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. The surveyor conducted a group meeting on 5/22/25 at 10:30 AM, with 5 alert and oriented residents chosen by the facility. Five of 5 residents stated they did not know where to find the State inspection results. On 5/23/25 at 12:20 PM, the surveyor looked for the most recent State inspection results on the A and B Nursing Units and was unable to locate them. On 5/23/25 at 12:30PM, during an interview with the surveyor, the Director of Nursing (DON) stated that the results of the last survey were in a binder on the shelf by the receptionist. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 4 of 29 residents; (2 unsampled residents) and (Resident #60 and #38) reviewed. The deficient practice was evidenced by the following: 1. On 5/20/25 at 1:05 PM, the surveyor observed in an Unsampled Resident's room (Room A21), the privacy curtain was soiled with a white substance on several areas of the curtain. On 5/20/25 at 1:15 PM, the surveyor observed in an Unsampled Resident's room (Room A28), the privacy curtain was soiled with a white substance on several areas of the curtain. The surveyor observed on the wall by the headboards brown material splattered across the entire wall, ceiling tiles buckled and displaced, chipped paint on the wall by the window, and the radiator in the bathroom was rusted and soiled. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 4 Residents (Resident # 20), reviewed for respiratory therapy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) accurate administration of medications for Resident #70, b.) documentation of the removal of controlled dangerous substance (narcotic; [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary environment that helped prevent the development and transmission of communicable diseases and infections. This was identified for 3 of 29 residents (Resident #20, #53 and #57) reviewed for infection control. The deficient practice was evidenced by the following: 1. a. On 5/20/2025 at 11:10 AM, the surveyor observed Resident #53 in their bed. The surveyor observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in the room with a humidifier bottle (a plastic bottle that infuses the normal flow of oxygen with water droplets) dated 10/25/24. The oxygen concentrator was not in use. The surveyor reviewed the medical record for Resident #53. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to a.) maintain a Packaged Terminal Air Conditioner and Heating Unit (PTAC) in safe and optimal condition in an unsampled resident's room (Room A 21-2), b.) failed to ensure that the grab bar was securely affixed to the bathroom wall next to the toilet in Resident #20's room (Room A28-2) and, c.) failed to maintain the heat register unit in Resident #57's room (Room A20-1). This deficient practice was evidenced by the following: On 5/20/25 from 1:05 PM-1:30 PM, the surveyor toured the A Nursing Unit and observed the following: -The PTAC unit in room [ROOM NUMBER]-2 had broken and missing vents. -The grab bar in the bathroom in room [ROOM NUMBER] was loose and affixed to a broken tile and there were also several missing tiles. [...]

Inspectors wroteBased 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 Tramadol (medication used for pain; [...]

Inspectors wroteComplaint # 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. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). The deficient practice was evidence by the following: Reference: According to the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic with an updated date of Sept. 23, 2022, included the following: [...]

Inspectors wroteBased 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. The leak is in the folding and preparing laundered personal resident clothing area. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to follow and maintain fall prevention interventions as ordered by the physician and as written on the resident's plan of care for one (1) of three (3) residents (Resident #94) reviewed for accidents. This deficient practice was evidenced by the following: On 3/10/23 at 10:36 AM, the surveyor observed Resident #94 lying in a low to the floor bed. The surveyor observed a blue floor mat that was upright on its side leaning against the right side of the bed. The surveyor did not observe a floor mat on the left side of the bed or anywhere else in the room. Resident #94 did not respond to the surveyor. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a) administer Tube Feeding (nutrition received through a flexible tube surgically inserted into the stomach) per the physician's order, b) document the total volume (TV) according to physician's order, and c) properly label the Tube Feeding (TF) bag according to the standard of clinical practice. This deficient practice was identified for one (1) of two (2) residents, (Resident #24) reviewed for receiving nutrition via TF and was evidenced by the following: On 3/10/23 at 11:52 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident #24 was on TF. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving oxygen (O2) treatment according to standards of practice. This deficient practice was identified for one (1) of one (1) resident (Resident #24) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/10/23 at 12:01 PM, the surveyor observed Resident#24 laying on the bed with the head of the bed elevated, and non-verbal. The surveyor observed that the resident had oxygen in use at 2LPM (two liters per minute) via a nasal cannula (consisting of two hollow prongs projecting from a hollow face piece) attached to a humidified oxygen concentrator (a medical device that gives extra oxygen). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 3/20/23, the surveyor observed four (4) nurses administer medications to four (4) residents. There were 29 opportunities, and two (2) errors were observed which resulted in a medication error rate of 6.9%. This deficient practice was identified for two (2) of four (4) nurses that administered medications to two (2) of four (4) residents (Resident #344 and Resident #31) and was evidenced by the following: 1) On 3/20/23 at 8:48 AM, the surveyor observed the Licensed Practical Nurse (LPN) take Resident #344's vitals, exited the room and cleaned the blood pressure cuff. [...]

Inspectors wroteComplaint # NJ00152736 Complaint # NJ00154046 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot food, cold food and drinks served to the residents. This deficient practice was identified for 2 (two) of 2 (two) residents, (Residents #80 and #27) confirmed during the lunchtime meal service on 3/22/23 for 2 (two) of 2 (two) nursing units tested for food temperatures by two surveyors and was evidenced by the following: On 3/22/23 at 11:52 AM, the surveyors and the Food Service Director (FSD) were on the A-Wing unit observing lunch tray distribution. At 11:57 PM, surveyor #1 pulled a tray from the food truck (Cart 1) in the A-Wing unit. The surveyor observed that Certified Nursing Assistants (CNA) began to deliver meal trays to residents at 11:55 AM. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of pertinent facility documentation, it was determined that the facility failed to provide the correct consistency of diet according to physician's order. This deficient practice was identified for one (1) of twenty-nine (29) sampled residents (Resident #81) during dining observation. The deficient practice was evidenced by the following: On 3/16/23 at 12:37 PM, the surveyor observed Resident #81 seated in a wheelchair in the main dining room with their lunch meal on the table in front of him/her. The surveyor observed Resident #81's lunch plate had two whole chicken thighs on it. The surveyor then reviewed Resident #81's lunch meal ticket which included the following: CHOPPED MEATS ONLY. The meat served to Resident #81 was not chopped and was not the correct consistency of diet ordered. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly dispose of and maintain the waste in garbage dumpster areas. This deficient practice was identified for one (1) of two (2) garbage dumpsters in the garbage disposal area. This deficient practice was evidenced by the following: During an observation on 3/13/23 at 11:14 AM by two surveyors and the Food Service Director (FSD), the outside dumpster area revealed two dumpsters next to each other. Dumpster #1 had a lid open with garbage bags in it. Dumpster #1 with trash around the surrounding area on the floor that included plastics, papers, and other garbage. There was a puddle of water near Dumpster #1. In addition, there was garbage soaked in the puddle of water. The FSD stated that she was not able to determine how long the garbage was on the floor. [...]

Inspectors wroteBased on observation, interview, and review of facility provided documents, it was determined that the facility failed to: a) perform hand hygiene appropriately for two (2) (Certified Nursing Aide and Housekeeper) of eight (8) staff and b) properly use PPE (personal protective equipment) for two (2) (Certified Nursing Aide and Housekeeper) of four (4) observed in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and facility policy. This deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on observation, interview, review of the medical records and other pertinent facility documents, it was determined that the facility failed to accurately follow the physician's orders for the administration of Oxygen. This deficient practice was observed for 1 of 2 residents reviewed for accuracy following the physician's oxygen orders, Resident #44. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation and interview on 3/24/21, it was determined that the facility failed to provide a safe and sanitary physical environment. This deficient practice was evidenced by the following