Alaris Health at West Orange

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyors observed 3 nurses administer medications for 5 residents with 25 opportunities for error. There were 6 errors resulting in an error rate of 24% as evidenced by the following: During the medication pass observation on 5/4/26 from 10:42 AM until 11:00 AM, the surveyor observed the following: At 10:42 AM, the surveyor observed Registered Nurse #1 (RN #1) prepare six medications for Resident #100, they were as follows: Aspirin chewable 81 mg (milligram) tablet, give one tablet by mouth one time a day; scheduled for 8:00 AM.Janumet 50/1000 mg tablet, give one tablet by mouth one time a day; scheduled for 9:00AM.Lisinopril 20 mg tablet, give one tablet one time a day; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to keep a safe, clean, and homelike environment for 1 of 3 floors reviewed for Environment. The deficient practice is evidenced by the following: On 05/05/2026 at 9:41 AM, during the initial tour of the facility, the surveyor observed inside-out disposable gloves left on top of a plastic bin outside of room [ROOM NUMBER]. On the same day at 9:44 AM behind the trash compactor, the surveyor observed multiple cigarette packages, a discarded wood pallet, and a sheet of metal. The items were located near the sewer basin. On the same day at 9:50 AM while in the second floor shower room, the surveyor observed an unwrapped incontinence brief hanging on the shower curtain. On 05/07/2026 at 12:38 PM, the surveyor informed the Licensed Nursing Home Administrator of the environmental findings. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to revise a care plan when there was a change in the physician's orders for a wander guard for 1 of 4 residents sampled for mood and behavior (Resident #85). This deficient practice was evidenced by the following:On 05/04/2026 at 10:26 AM, during the initial tour, the surveyor observed Resident #85 pacing in the hallway. On 05/05/2026 at 9:47 AM, the surveyor observed Resident #85 pacing the hallway. A review of Resident #85's electronic medical record (EMR) revealed that the resident was admitted with, but not limited to, Alzheimer's Disease (a progressive brain disorder that affects memory, thinking, and behavior). A review of Resident #85's physician's orders revealed that the resident's wander guard was discontinued on 02/17/2026. [...]

Inspectors wroteBased on observation, interview, review of closed medical records and review of other facility documentation, it was determined that the facility failed to consistently provide a resident with pressure ulcers the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcer development for 1 of 2 residents reviewed for hospitalization (Resident #4). The evidence was as follows:On 5/5/2026 at 10:36 AM, the surveyor reviewed the closed electronic medical record (EMR) for Resident #4 who had been discharged from the facility. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) follow appropriate infection control practices and perform hand hygiene as indicated during Medication Pass observation. This deficient practice was identified for 1 of 5 residents reviewed for medication pass (Resident # 100). This deficient practice was evidenced by the following:On 5/04/2026 from 10:42 AM through 11:00 AM, the surveyor during Medication Pass observation of Registered Nurse #1 (RN #1) made the following observations:RN #1 was standing in front of the medication cart while she prepared medication for Resident #100. The surveyor did not see RN #1 perform any type of hand hygiene. [...]

Inspectors wroteComplaint #: 2688530Based on interviews, review of medical records, and review of other pertinent facility documents on 12/22/2025, it was determined that the facility failed to ensure that residents received care and services necessary to attain or maintain the highest practicable physical well-being, in accordance with professional standards of practice, by failing to timely assess, monitor and implement appropriate interventions for identified skin integrity concerns. This deficient practice was identified for 2 of 3 residents reviewed (Resident #1 and Resident #2), as 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: [...]

Inspectors wroteBased on interview and record review, the facility failed to keep Resident #103 safe from accidents/injury. Resident #103 sustained lacerations to two fingers which resulted in both fingers being amputated after a side rail fell on Resident #103's right hand while staff were providing care for the resident. This deficient practice was identified for one (1) of three (3) residents (Resident (R) #103) reviewed for accident hazards. This failure caused serious harm to R #103 and had the potential to place all residents with side rails at risk.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure that bedroom flooring was fixed for one of 26 sample residents (Resident (R) 37) reviewed for environment. This failure had the potential to affect resident safety.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was free from physical restraints for one of one resident (Resident (R) 64) reviewed for physical restraints out of 26 sample residents. This failure had the potential to affect all residents' rights at the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I assessment was completed accurately for one of three residents (Resident (R) 64) reviewed for level I PASARR screenings of 26 sample residents. This failure had the potential to prevent or delay additional services for a resident that may qualify for level II.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to accommodate one of one resident's (Resident (R) 98) dietary preferences reviewed for food choices of 26 sample residents. This failure had the potential to cause emotional distress and nutritional deficit.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure for one of one resident (Resident (R) 22) reviewed for activities of daily living (ADL) care had complete and accurate medical records of 26 sample residents. This continued practice did not ensure the medical record accurately reflected the care of the residents.

Inspectors wroteBased upon observation, interview, record review, document review, and review of facility policies, the facility failed to ensure that menus/food provided to residents met the individual needs for four (Resident (R) 312, R19, R104 and R15) of 28 sampled residents, and an additional five (R89, R62, R63, R91, and R6) supplemental residents. Although food allergies and textures were noted in physician orders and/or dietary records, two sampled residents (R 312 and R89) were provided foods to which they had documented allergies and/or which was in a texture could be unsafe to consume. Additional supplemental residents, (R19, R62, R63, R91, and R6) who had cognitive impairment which could affect their ability to recognize unsafe foods (either due to allergy or texture) were also placed at risk due to the facility's failure. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure three (Residents (R)18, R205, R311) of three sampled residents, out of a total of nine residents who required respiratory care, received care consistent with professional standards of practice. The facility failed to maintain the cleanliness of the oxygen concentrator filter for R18 and failed to place a filter on the back of the oxygen concentrator for R205. In addition, the facility failed to ensure tubing was changed and/or dated as needed for R205 and R311.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess competency and care plan for self-administration of medications for one of five residents (Resident (R) 18) observed during medication pass in a total sample of 28 residents. The resident, who did not have physician orders for self-administration of medication and was not assessed/care planned for self-administration, was observed to instill two drops of medication for glaucoma into each eye, instead of one drop into each eye as ordered by the physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one (Resident (R) 92) in a total sample of 28 residents whose assessments were reviewed. The facility failed to accurately assess R92's hospice status after the resident was discharged from hospice care.

Inspectors wroteBased on observation, interview, record review and review of policy and procedures, the facility failed to ensure that physician orders were followed for one (Resident (R) 56) of 28 sampled residents. The facility failed to assure that anti-embolism (TED) stockings were applied daily as ordered.

Inspectors wroteBased on observation, interview, record review, and review of facility policy and procedures, the facility failed to ensure appropriate infection control measures, including hand hygiene and glove changes, were implemented during wound care for one (Resident (R) 16) of 28 sampled residents. A Registered Nurse (RN) failed to doff soiled gloves and/or perform hand hygiene after removing/handling a soiled dressing, prior to cleaning the resident's wound and applying a new, clean dressing. In addition, the RN failed to handle soiled materials in a manner designed to prevent the spread of infection.