Inspection Reports for Alaris Health At West Orange
5 Brook End Drive, West Orange, NJ, 07052
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
209 residents
Based on a August 2022 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 22, 2025
Visit Reason
The inspection was conducted based on complaint #2688530 to investigate allegations that the facility failed to ensure residents received necessary care to maintain skin integrity, specifically timely assessment, monitoring, and intervention for skin concerns.
Complaint Details
Complaint #2688530: The facility failed to ensure residents received care necessary to maintain skin integrity, including timely assessment and intervention for pressure injuries and wounds, as evidenced by two residents with untreated or poorly managed pressure ulcers and abscesses.
Findings
The facility was found deficient in providing timely assessment, monitoring, and appropriate interventions for skin integrity issues for two residents. Deficiencies included lack of care plans, delayed wound care orders, incomplete documentation, and failure to initiate care plans within required timeframes.
Deficiencies (1)
Failure to timely assess, monitor, and implement appropriate interventions for identified skin integrity concerns in two residents.
Report Facts
Residents reviewed: 3
Residents affected: 2
Pressure injury sites for Resident #1: 4
BIMS score Resident #1: 14
BIMS score Resident #2: 13
Open wound size Resident #2: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Interviewed regarding skin assessment and care plan procedures | |
| Director of Nursing | Interviewed regarding deficiencies in care plan initiation and documentation | |
| Nurse Practitioner | Provided progress notes and orders related to wound care |
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 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
Deficiencies: 2
Date: Dec 19, 2024
Visit Reason
The inspection was conducted based on complaints regarding environmental safety and accident hazards in the facility, specifically concerning a damaged bedroom floor and an incident involving a side rail injury to a resident.
Complaint Details
The complaint investigation revealed that Resident #103 sustained serious injury due to a side rail falling on their hand during care, resulting in lacerations and amputation of two fingers. The incident occurred on 03/26/23, and the facility failed to ensure side rails were secure and safe. Interviews with staff and review of records confirmed the incident and inadequate supervision and maintenance related to side rails.
Findings
The facility failed to ensure safe environmental conditions by not repairing damaged bedroom flooring, posing a fall risk to residents. Additionally, the facility failed to keep Resident #103 safe from accident hazards, resulting in serious harm when a side rail fell on the resident's hand causing lacerations and subsequent amputation of two fingers.
Deficiencies (2)
Failed to ensure bedroom flooring was fixed, exposing concrete and creating a hazard.
Failed to keep Resident #103 safe from accident hazards; side rail fell causing lacerations and amputation of two fingers.
Report Facts
Residents reviewed for environment: 26
Resident #103's BIMS score: 99
Resident #37's BIMS score: 15
Date of water overflow in Resident #37's room: Nov 24, 2024
Date of side rail injury incident: Mar 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Provided nurse's notes describing the side rail injury incident and care given |
| Licensed Practical Nurse #2 | LPN | Documented verbal consent for side rails for Resident #103 |
| Director of Nursing | DON | Interviewed regarding staff responsibilities for side rail safety |
| Certified Nurse Aide #5 | CNA | Interviewed about the side rail incident and care provided to Resident #103 |
| Regional Maintenance Director | RMD | Verified floor condition and requested immediate repair |
| Maintenance Director | MD | Interviewed about delay in floor repair work |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, use of physical restraints, PASARR screening, accident hazards, dietary preferences, and medical record documentation at Alaris Health at West Orange.
Findings
The facility was found deficient in multiple areas including failure to repair bedroom flooring posing safety risks, improper use of physical restraints without consent, inaccurate PASARR Level I screening, serious injury caused by side rail accident, failure to accommodate dietary preferences, and incomplete medical record documentation for activities of daily living.
Deficiencies (6)
Failed to ensure bedroom flooring was fixed causing potential resident safety hazard.
Failed to ensure a resident was free from physical restraints without consent.
Failed to complete PASARR Level I screening accurately, potentially delaying services.
Failed to keep resident safe from accident hazards; side rail fell causing finger amputations.
Failed to accommodate resident dietary preferences causing potential emotional distress.
Failed to maintain complete and accurate medical records for resident activities of daily living.
Report Facts
Residents reviewed: 26
Resident R37 sample size: 1
Resident R64 sample size: 1
Resident R103 sample size: 1
Resident R98 sample size: 1
Resident R22 sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 1 | Unit Manager | Mentioned in relation to placing wander guard on Resident R64 and documentation issues |
| Director of Nursing | Director of Nursing | Provided statements regarding wander guard use, PASARR screening, dietary preferences, and documentation |
| Assistant Director of Nursing | Assistant Director of Nursing | Wrote nurse's note regarding Resident R64's hallucinations and psychiatric consult |
| Registered Nurse 2 | Registered Nurse | Wrote nurse's notes and interviewed regarding Resident R64's condition and wander guard use |
| Regional Maintenance Director | Regional Maintenance Director | Verified condition of floor and requested repair |
| Maintenance Director | Maintenance Director | Interviewed about delay in floor repair |
| Admissions Director | Admissions Director | Interviewed about PASARR screening accuracy |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Provided care and documented injury for Resident R103 |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Provided care and documented injury for Resident R103 |
| Certified Nurse Aide 5 | Certified Nurse Aide | Witnessed side rail incident involving Resident R103 |
| Certified Nurse Aide 1 | Certified Nurse Aide | Confirmed Resident R98 received pork meal |
| Certified Nurse Aide 4 | Certified Nurse Aide | Interviewed about documentation of ADLs |
| Registered Dietician | Registered Dietician | Interviewed about dietary preferences and meal accommodations |
| Dietary Manager | Dietary Manager | Interviewed about dietary preferences and meal accommodations |
Inspection Report
Follow-Up
Census: 106
Deficiencies: 1
Date: Aug 12, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey staffing requirements for nursing homes, specifically focusing on maintaining minimum direct care staff-to-resident ratios.
Findings
The facility was found deficient in maintaining the required minimum direct care staff-to-resident ratios on multiple day shifts in July 2022, with fewer certified nurse aides (CNAs) than required. A plan of correction was submitted and later verified as completed on 09/09/2022.
Deficiencies (1)
Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Residents present: 109
Residents present: 104
Residents present: 100
Residents present: 106
Residents present: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for reviewing staffing daily and approving or denying time off requests to ensure compliance with staffing ratios |
Inspection Report
Routine
Census: 103
Deficiencies: 6
Date: Aug 12, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident assessments, treatment and care, respiratory care, nutritional services, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to assess and care plan for medication self-administration, inaccurate resident assessments, failure to follow physician orders for treatments, inadequate respiratory care including failure to maintain oxygen equipment, failure to ensure menus met residents' nutritional needs and allergies resulting in immediate jeopardy, and failure to implement proper infection control measures during wound care.
Deficiencies (6)
Failed to assess competency and care plan for self-administration of medications for one resident who instilled two drops of eye medication instead of one as ordered.
Failed to ensure accuracy of Minimum Data Set assessment for one resident regarding hospice status.
Failed to ensure physician orders were followed for application of anti-embolism stockings for one resident.
Failed to provide safe and appropriate respiratory care for three residents, including failure to maintain oxygen concentrator filters and tubing changes.
Failed to ensure menus met nutritional needs, accommodated allergies and preferences for multiple residents, resulting in immediate jeopardy due to risk of serious harm or death.
Failed to implement appropriate infection prevention and control measures during wound care for one resident, including failure to change gloves and perform hand hygiene between dirty and clean procedures.
Report Facts
Residents requiring respiratory treatment: 9
Total census: 103
Sample size: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Named in medication self-administration deficiency |
| LPN2 | Licensed Practical Nurse, Unit Manager | Verified no physician order or care plan for medication self-administration; involved in multiple interviews |
| Consultant Pharmacist | Verified physician order for eye drops and commented on effects of overdose | |
| RN3 | Registered Nurse | Interviewed regarding oxygen tubing and filter maintenance |
| RN1 | Registered Nurse | Observed and interviewed regarding oxygen tubing and filter maintenance and wound care |
| LPN1 | Licensed Practical Nurse | Interviewed regarding TED stockings order and implementation |
| Dietary Manager | Interviewed regarding food allergy incident and menu process | |
| CNA1 | Certified Nursing Assistant | Interviewed regarding food allergy incident and tray checks |
| CNA2 | Certified Nursing Assistant | Involved in food tray delivery incident |
| OTR1 | Occupational Therapy Assistant | Delivered incorrect meal tray to resident |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including menus and respiratory care |
| Medical Director | Medical Director | Interviewed regarding food allergy incident |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Date: Nov 20, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint intakes NJ148464, NJ147280, and NJ147162, to investigate allegations of neglect and compliance with quality of care regulations.
Complaint Details
Complaint investigation based on complaint intakes NJ148464, NJ147280, and NJ147162. The complaint was substantiated with findings of neglect related to failure to carry out physician's lab orders for a resident.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, specifically failing to implement a physician's order to obtain lab work for a resident, indicating deficient quality of care. The facility was compliant with COVID-19 infection control regulations.
Deficiencies (1)
Failure to implement a physician's order to obtain lab work for one resident, resulting in neglected care.
Report Facts
Sample Size: 5
Deficiency Correction Completion Date: Correction for deficiency F684 completed on 11/29/2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | In-serviced all nurses to ensure physician orders are carried out promptly | |
| Administrator | Interviewed regarding physician order entry process and missed lab orders | |
| Nurse Aide #1 | Nurse Aide | Interviewed about resident's condition and care |
| Physician | Interviewed regarding missed lab orders and responsibility for order entry |
Inspection Report
Routine
Census: 93
Deficiencies: 0
Date: Jan 26, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 15, 2020
Visit Reason
The inspection was conducted based on observations, interviews, and record reviews related to medication administration, pharmaceutical services, infection control, and facility safety compliance.
Complaint Details
The visit was complaint-related, triggered by observations and reports of medication administration errors, pharmaceutical service deficiencies, infection control lapses, and environmental safety concerns including smoking policy violations.
Findings
The facility was found deficient in multiple areas including failure to maintain accurate medication accountability and documentation, failure to act on pharmacist recommendations, improper infection control practices during blood sugar testing, and failure to enforce smoke-free environment policies.
Deficiencies (4)
Failure to maintain accurate accountability and reconciliation for controlled drug Oxycodone and failure to ensure medications administered were signed in the eMAR at the time of administration.
Failure to act on or respond to recommendations made by the Consultant Pharmacist during the Monthly Medication Review for unnecessary medications.
Failure to follow appropriate infection control practices by not wearing gloves when testing a resident's blood sugar.
Failure to ensure implementation of Smoke Free Environment policy, including allowing unauthorized smoking and lack of proper receptacles for cigarette remnants.
Report Facts
Oxycodone tablets remaining: 23
Oxycodone tablets counted: 22
Physician progress notes count: 31
APN progress notes count: 3
APN Palliative Care Follow-up progress notes count: 11
Total physician and APN assessments: 45
Coreg medication hold instances: 15
Smoking contract signed date: 2019
Number of cigarette butts observed: 20
Number of cigarette butts observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #63 | Resident | Involved in medication administration discrepancy and smoking policy violation |
| Resident #17 | Resident | Involved in narcotic medication count discrepancy and smoking policy violation |
| Director of Nursing | DON | Provided expectations on medication administration and narcotic documentation |
| Assistant Director of Nursing | ADON | Provided information on medication administration and infection control expectations |
| Licensed Practical Nurse | LPN | Observed administering medications and involved in medication documentation errors |
| Registered Nurse/Unit Manager | RN/UM | Reviewed pharmacist recommendations and physician reports |
| Unit Manager | UM | Interviewed regarding smoking assessments and resident smoking |
| Social Worker | SW | Interviewed regarding smoking policy and resident smoking |
| Administrator | Administrator | Provided information on facility smoking policy and observations |
| MDS Coordinator | MDS Coordinator | Provided infection control training and expectations |
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