Inspection Reports for Alaris Health At St Mary’s
135 South Center Street, NJ, 07050
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
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Moderate
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Census Over Time
Census
Capacity
Notice
Deficiencies: 0
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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their 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
Complaint Investigation
Census: 163
Deficiencies: 0
Jul 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ00186176, NJ00186202, NJ00186271, NJ00186936, and NJ00187812.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint investigation with multiple complaint numbers; the facility was found in substantial compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 164
Deficiencies: 2
Apr 15, 2025
Visit Reason
The inspection was conducted based on complaint NJ00185165 to determine compliance with discharge planning and medically related social services requirements at Alaris Health at St Mary's.
Findings
The facility was found not in substantial compliance with discharge planning and medically related social services requirements, specifically failing to implement and document an effective discharge plan for Resident #2, and failing to provide medically related social services as required. The Regional Quality Assurance RN and Social Workers were involved in discharge planning processes, and corrective actions including audits and checklists were planned.
Complaint Details
Complaint # NJ00185165 triggered the investigation. The facility was found not in substantial compliance with discharge planning and medically related social services requirements based on observations, interviews, and record reviews related to Resident #2.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement an effective discharge planning process ensuring safe and effective transition of care for residents, evidenced by Resident #2's discharge planning deficiencies. | SS=D |
| Failure to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents, evidenced by failure to assist Resident #2 in obtaining needed services and follow discharge policy. | SS=D |
Report Facts
Census: 164
Sample Size: 4
Deficiencies cited: 2
Plan of Correction Completion Dates: May 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to auditing planned discharges and reporting audit results |
Inspection Report
Routine
Census: 156
Capacity: 156
Deficiencies: 12
Jan 23, 2025
Visit Reason
A recertification/LSC survey was conducted at Alaris Health at St. Mary's from 1/15/25 through 1/23/25 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The survey identified a finding constituting an Immediate Jeopardy (IJ) related to failure to follow policies to ensure effective interventions were implemented and monitored for residents with a history of falls. The facility was found to be in compliance with the New Jersey Administrative Code standards for licensure of Long Term Care Facilities. Multiple deficiencies were cited related to resident rights, admission and discharge, quality of care, infection control, and safety.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to follow policies to ensure effective interventions were implemented and monitored for residents with a history of falls, constituting Immediate Jeopardy. | Immediate Jeopardy |
| Failure to maintain a safe, clean, comfortable, and homelike environment including proper maintenance of handrails and other safety features. | — |
| Failure to ensure residents' rights to dignity, respect, and privacy. | — |
| Failure to ensure proper administration and monitoring of medications. | — |
| Failure to ensure proper transfer and care of residents requiring assistance. | — |
| Failure to ensure adequate supervision and assistance to prevent accidents and injuries. | — |
| Failure to maintain infection prevention and control program including proper use of PPE and isolation precautions. | — |
| Failure to maintain accurate and complete assessments and care plans. | — |
| Failure to ensure proper notification and documentation of incidents and changes in condition. | — |
| Failure to ensure proper administration of oxygen therapy and respiratory care. | — |
| Failure to maintain compliance with smoking safety policies and procedures. | — |
| Failure to maintain proper arbitration agreements and resident rights documentation. | — |
Report Facts
Census: 156
Total Capacity: 156
Sample Size: 32
Closed Records: 4
Survey Dates: 2025-01-15 to 2025-01-23
Inspection Report
Annual Inspection
Census: 148
Capacity: 188
Deficiencies: 8
Sep 18, 2023
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 failure to address full code status orders, inaccurate Minimum Data Set coding, failure to revise comprehensive care plans timely, failure to follow clinical practice standards including medication administration and pain management, failure to maintain proper nutrition and hydration documentation, and failure to maintain proper kitchen sanitation practices. Life Safety Code deficiencies were also cited related to fire door hardware and inspection.
Severity Breakdown
SS=D: 6
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to address a full code status order signed by resident's family with no follow up from physician. | SS=D |
| Facility failed to accurately code the Minimum Data Set (MDS) for residents. | SS=D |
| Facility failed to revise residents' comprehensive care plans timely. | SS=D |
| Facility failed to follow acceptable clinical practice standards regarding medication administration, pain management, and documentation. | SS=D |
| Facility failed to maintain acceptable nutritional status documentation, weekly weights, and care plans addressing weight loss causes. | SS=D |
| Facility failed to maintain proper kitchen sanitation practices; dishwasher temperature did not reach minimum required 120°F. | SS=D |
| Fire rated stairway exit doors were equipped with panic hardware instead of required fire exit hardware. | SS=F |
| Fire doors were not properly inspected and documented annually as required by NFPA 101 Life Safety Code. | SS=F |
Report Facts
Census: 148
Total Capacity: 188
Deficiencies cited: 8
Dishwasher temperature: 114
Dishwasher temperature required: 120
Fire door replacement completion date: Oct 17, 2023
Life Safety Code survey date: Sep 7, 2023
Inspection Report
Abbreviated Survey
Census: 148
Deficiencies: 1
Apr 5, 2023
Visit Reason
A Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to Candida auris.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to minimize the spread of infection during an outbreak. Deficient practices related to hand hygiene and transmission-based precautions were identified for two residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to minimize the spread of infection during a Candida auris outbreak, including inadequate hand hygiene and transmission-based precautions by staff. | SS=D |
Report Facts
Sample size: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Identified and re-educated on handwashing and infection control related to transmission based precautions |
| CNA #2 | Certified Nursing Assistant | Identified and re-educated on handwashing and infection control related to transmission based precautions |
| RN #1 | Registered Nurse | Identified and re-educated on 24 hour hand-off communication and shown assignment/communication sheets indicating precautions |
| RN #2 | Registered Nurse | Involved in communication and education regarding residents on transmission based precautions |
| Assistant Director of Nursing/Infection Preventionist (ADON/IP) | Provided statements about infection control practices and education | |
| Nurse Educator | In-serviced direct care staff on communication huddle and infection control precautions | |
| Regional Quality Assurance Registered Nurse (RQARN) | Provided information about supervisory roles and audit findings |
Inspection Report
Annual Inspection
Census: 135
Deficiencies: 4
Jan 13, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
Deficiencies were cited related to failure to develop and implement comprehensive care plans, failure to meet professional nursing standards in medication administration and care, failure to follow physician orders for respiratory care, and failure to ensure physicians signed and dated monthly orders for multiple residents.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to develop a comprehensive care plan for floor maintenance program and failure to revise restorative nursing program care plan after discontinuation. | SS=D |
| Failure to follow accepted nursing standards of practice while administering medication and applying treatment without physician's order. | SS=D |
| Failure to follow physician's order for administration of respiratory care. | SS=D |
| Failure to ensure residents' primary physicians signed and dated monthly physician orders. | SS=F |
Report Facts
Census: 135
Sample Size: 30
Residents with unsigned monthly physician orders: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager (RNUM) | Interviewed regarding care plan deficiencies and physician order signing | |
| Director of Nursing (DON) | Interviewed regarding care plan deficiencies, respiratory care, and physician order signing | |
| Administrator | Interviewed regarding care plan deficiencies and physician order signing | |
| Licensed Practical Nurse (LPN) | Observed administering medication and interviewed about medication administration practices | |
| Unit Manager (UM) | Interviewed regarding monitoring oxygen settings and physician order compliance |
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 0
Jul 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ145825, NJ144944, NJ141623, and NJ141545.
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.
Complaint Details
Complaint numbers NJ145825, NJ144944, NJ141623, and NJ141545 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 22
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 0
Dec 18, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ00140971.
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.
Complaint Details
Complaint #: NJ00140971; the survey was complaint-based and the facility was found compliant.
Report Facts
Sample Size: 4
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