Inspection Reports for
Alaris Health At Kearny
206 Bergen Ave, Kearny, NJ, 07032
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
90% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, and facility operations at Alaris Health at Kearny.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach, honoring resident food reheating preferences, developing comprehensive care plans for anticoagulant use, providing adequate shower assistance and documentation, ensuring residents on dialysis received snacks and fluids, following physician-ordered medication parameters, and maintaining safe bed rails.
Deficiencies (7)
Failed to ensure call light was within reach for one resident, potentially causing unmet care needs.
Failed to honor residents' choices to have their food warmed by staff after 7:00 PM daily.
Failed to develop a comprehensive care plan with measurable goals and interventions for anticoagulant use for one resident.
Failed to provide assistance with showering and proper documentation for one resident, increasing potential for unmet hygiene needs.
Failed to ensure one resident on dialysis was offered snacks/fluids during dialysis days and failed to accurately document nutritional intake.
Failed to follow physician-ordered parameters for blood pressure medications, administering antihypertensives when systolic BP was below ordered threshold.
Failed to conduct regular inspections and timely repairs of bed rails, resulting in loose and unsafe bed rails for one resident.
Report Facts
Residents reviewed: 26
Residents affected: 1
Residents affected: 99
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Shower opportunities: 16
Showers given: 4
Bed baths given: 2
Shower refusals: 9
Blood pressure readings below parameter: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Confirmed staff responsibility for call light accessibility and medication administration practices |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Observed and confirmed call light placement issues |
| Director of Nurses | Director of Nursing | Interviewed regarding care planning and dialysis snack policy |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Provided information on shower assistance and documentation |
| Registered Nurse 3 | Registered Nurse | Administered medications to resident R105 and discussed medication administration discrepancies |
| Regional Maintenance Director | Maintenance Director | Discussed bed rail repair process and communication issues |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 119
Deficiencies: 7
Date: Sep 27, 2024
Visit Reason
A Recertification and Complaint Survey was conducted due to complaint NJ167344 and routine recertification requirements.
Complaint Details
Complaint # NJ167344 triggered the survey. The facility was found not in substantial compliance with multiple regulatory requirements including resident accommodations and care planning.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with deficiencies related to reasonable accommodations, self-determination, comprehensive care plans, nutrition/hydration, drug regimen, resident bed safety, and life safety code violations.
Deficiencies (7)
Reasonable Accommodations Needs/Preferences not met for Resident #69.
Self-Determination rights not met for 99 of 107 residents regarding food warming and choices.
Comprehensive Care Plans failed to develop measurable goals and interventions for Resident #105.
Nutrition/Hydration Status Maintenance failure for Resident #51 regarding snack provision.
Drug Regimen not free from unnecessary drugs for Resident #105.
Resident Bed safety issues including bed rails and maintenance for Resident #63.
Life Safety Code violations related to fire pump testing and fire door inspections.
Report Facts
Survey Census: 107
Total Capacity: 119
Sample Size: 26
Deficiency Severity Counts: 7
Inspection Report
Deficiencies: 5
Date: Oct 18, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, assessment data transmission, respiratory care, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to maintain accessible call bells for residents, untimely transmission of Minimum Data Set (MDS) assessments, improper medication management including failure to remove discontinued medications and inaccurate medication administration, lack of physician order for oxygen therapy, and failure to notify hospice agency of significant resident status changes and death.
Deficiencies (5)
Failed to maintain resident call bells accessible and within reach of all residents (Resident #64).
Failed to complete and transmit Minimum Data Set (MDS) assessments within required timeframe (Resident #1).
Failed to appropriately remove, clarify, accurately administer, and document resident's physician ordered medications (Residents #22, #23, #24, #54, #73, #80, #93, #57).
Failed to obtain a physician's order for the administration of oxygen (Resident #62).
Failed to immediately notify the hospice agency about a significant change in a resident's condition and a resident's death (Resident #83).
Report Facts
Residents reviewed for medication deficiencies: 8
Residents reviewed for respiratory care: 3
Residents reviewed for hospice/end-of-life care: 3
MDS transmission delay days: 40
Medication doses in bottle: 120
Medication doses in bottle: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding Resident #64 call bell accessibility | |
| Licensed Practical Nurse (LPN) | Interviewed regarding Resident #64 call bell accessibility and medication administration | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding Resident #64 call bell accessibility and oxygen therapy order | |
| Maintenance Director | Interviewed regarding repair of Resident #64 call bell | |
| Registered Nurse Infection Preventionist (RNIP) | Interviewed regarding medication administration and MDS transmission | |
| Provider Pharmacy Registered Pharmacist (PPRPh) | Interviewed regarding medication supply and administration | |
| Consultant Registered Pharmacist | Interviewed regarding medication crushing for Resident #93 | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding multiple deficiencies including medication management and oxygen therapy | |
| Regional Quality Assurance Nurse (RQAN) | Interviewed regarding multiple deficiencies including medication management and oxygen therapy | |
| President of Operations (VPO) | Interviewed regarding multiple deficiencies including medication management and oxygen therapy | |
| RN Case Manager (RN/CM) from hospice agency | Interviewed regarding failure to notify hospice of resident status change and death | |
| Registered Nurse (RN) | Interviewed regarding Resident #83 status change and death notification |
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 13
Date: Oct 18, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident call bell accessibility, timely completion and transmission of Minimum Data Set (MDS) assessments, medication administration errors, lack of physician orders for oxygen administration, and failure to notify hospice of significant resident status changes. Life safety code deficiencies included emergency lighting, fire alarm system maintenance, sprinkler system installation, smoke barrier door integrity, HVAC boiler inspections, elevator inspections, and essential electrical system testing.
Deficiencies (13)
Facility failed to maintain resident call bells accessible and within reach of all residents.
Facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines.
Facility failed to appropriately remove, clarify, accurately administer, and document resident's physician ordered medications.
Facility failed to obtain a physician's order for the administration of oxygen for a resident.
Facility failed to immediately notify the hospice agency about a significant change in a resident's condition and death.
Facility failed to provide emergency illumination of means of egress that operates automatically.
Facility failed to provide battery back-up emergency lighting above the emergency generator and fire pump transfer switches.
Facility failed to provide complete sprinkler coverage in stairwells as required.
Facility failed to maintain fire alarm system in accordance with NFPA 70 and 72; fire alarm annunciator panel in trouble mode.
Facility failed to ensure smoke barrier doors fully close to resist passage of smoke, flame, or gases during a fire.
Facility failed to ensure heating boilers were inspected annually as required.
Facility failed to ensure elevators conformed with Firefighter's Service Requirements and failed to test and inspect elevators annually.
Facility failed to certify that the emergency generator transfers power to the building within 10 seconds as required.
Report Facts
Census: 98
Sample Size: 20
Deficiency count: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed findings related to emergency lighting, fire alarm, sprinkler coverage, smoke doors, boiler inspections, elevator inspections, and generator testing. | |
| Regional Plant Operations Director | Interviewed and confirmed findings related to emergency lighting, fire alarm, sprinkler coverage, smoke doors, boiler inspections, elevator inspections, and generator testing. | |
| Licensed Nursing Home Administrator | Interviewed regarding medication administration deficiencies, oxygen orders, hospice notification, and life safety code deficiencies. | |
| Regional Quality Assurance Nurse | Interviewed regarding medication administration deficiencies, oxygen orders, hospice notification, and life safety code deficiencies. | |
| Vice President of Operations | Interviewed regarding medication administration deficiencies, oxygen orders, hospice notification, and life safety code deficiencies. | |
| Registered Nurse MDS Coordinator | Interviewed regarding MDS assessment completion and transmission. | |
| Regional MDS Coordinator | Interviewed regarding MDS submission validation. | |
| Registered Nurse Infection Preventionist | Interviewed regarding medication administration and oxygen order deficiencies. | |
| Consultant Registered Pharmacist | Interviewed regarding medication crushing practices. | |
| Licensed Practical Nurse | Interviewed regarding medication administration and call bell deficiencies. | |
| Certified Nurse Assistant | Interviewed regarding call bell accessibility and oxygen administration. | |
| RN Case Manager | Interviewed regarding hospice notification failures. | |
| Registered Nurse | Interviewed regarding hospice notification failures. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Jul 8, 2022
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ153575.
Complaint Details
Complaint #: NJ153575. The facility was found compliant based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Feb 15, 2022
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ142943) to assess compliance with long term care facility regulations.
Complaint Details
Complaint #: NJ142943. The facility was found to be in compliance with the complaint survey requirements.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B, based on this complaint survey. Additionally, a COVID-19 Focused Infection Control Survey found the facility compliant with infection control regulations and CDC recommended practices.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Jan 12, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ00136968.
Complaint Details
Complaint #: NJ00136968. The facility was found compliant based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 10
Inspection Report
Routine
Census: 96
Deficiencies: 0
Date: Jan 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Routine
Deficiencies: 4
Date: Sep 16, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, care planning, infection control, and safety measures in the nursing home.
Findings
The facility was found deficient in ensuring residents were offered the opportunity to formulate advance directives, developing comprehensive care plans for residents receiving oxygen therapy, updating care plans for resident safety during smoking, and maintaining proper hand hygiene during food tray distribution. These deficiencies were associated with minimal harm or potential for actual harm to residents.
Deficiencies (4)
Failed to ensure that four residents were offered the opportunity to formulate an Advance Directive.
Failed to develop a comprehensive, person-centered Care Plan for residents treated with Oxygen Therapy.
Failed to review and revise a care plan to include updated interventions for a resident's safety and compliance during smoking.
Failed to adhere to accepted standards of infection control prevention for hand hygiene and the distribution of food trays to maintain sanitation.
Report Facts
Residents reviewed for advance directive planning: 21
Residents reviewed for comprehensive care plans: 21
Residents reviewed for care plan related to smoking: 21
Units observed for food tray distribution: 2
Residents affected by advance directive deficiency: 4
Residents affected by oxygen therapy care plan deficiency: 2
Residents affected by smoking care plan deficiency: 1
Residents affected by food tray hygiene deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Director of Social Services | Stated that Residents #4, #46, #32, and #88 had no advance directives and should have discussed and had them in place. |
| Registered Nurse | Registered Nurse | Interviewed regarding oxygen therapy care plans for Residents #47 and #34; unable to locate care plans for oxygen therapy. |
| Staffing Coordinator | Staffing Coordinator | Observed escorting Resident #23 to smoking area and interacting regarding smoking apron use. |
| Certified Nursing Assistant | Certified Nursing Assistant | Assigned to supervise Resident #23 during smoking; reported resident's compliance with smoking apron. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed delivering food trays without hand hygiene between residents. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed delivering food trays and setting up meals without hand hygiene between residents. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed delivering food trays without hand hygiene; acknowledged forgetting to wash hands. |
| Administrator | Administrator | Discussed oxygen therapy care plans and smoking safety concerns with surveyor. |
| Director of Nursing | Director of Nursing | Participated in discussions about oxygen therapy care plans and smoking safety; acknowledged resident noncompliance. |
| Regional VP of Operations | Regional VP of Operations | Participated in discussions about oxygen therapy care plans, smoking safety, and food tray hand hygiene. |
| Quality Assurance Registered Nurse | Quality Assurance Registered Nurse | Participated in discussions about oxygen therapy care plans, smoking safety, and food tray hand hygiene. |
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