Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alaris Health At West Orange during CMS and state inspections, most recent first.
Two residents with significant skin integrity concerns did not receive timely assessment, documentation, or initiation of care plans and wound care orders as required by facility policy and professional standards. Delays in care plan initiation and documentation, as well as missed physician orders, resulted in inadequate management of pressure injuries and wounds.
A resident with Alzheimer's was injured when an unsecured side rail fell, leading to finger amputations. The resident was holding the rail for support during care when it detached. Staff failed to check the rail's stability, and the facility's policy on side rail security was not followed, resulting in serious harm.
A resident's bedroom in the facility had a flooring issue due to a leak from the faucet/sink, causing water overflow and buckling of the linoleum. Despite the problem being noted, it was not properly documented or addressed, leaving a section of missing tile and exposed concrete. The Maintenance Director delayed repairs, waiting for the survey to finish, contrary to the facility's policy requiring repair concerns to be logged.
A resident with schizoaffective disorder and a high BIMS score was fitted with a wander guard without consent, despite no documented exit-seeking behavior. Staff applied the device as a precaution for safety, but the resident expressed that it restricted her freedom to go outside. The facility's policy requires consent and clinical justification for restraints, which was not adhered to in this case.
A facility failed to ensure an accurate PASARR Level I assessment for a resident with mental health diagnoses, as the assessment completed by the hospital did not indicate any mental illness or psychiatric history. The Admissions Director and DON did not verify the accuracy of the PASARR, relying on the hospital's completion, which led to potential delays in additional services for the resident.
A resident with a documented preference for no pork was served a meal containing pork, despite her request for an alternative. The resident, who was cognitively intact, did not receive a replacement meal, contrary to the facility's policy on respecting food preferences. This incident was confirmed by staff interviews and had the potential to cause emotional distress and nutritional deficit.
A facility failed to maintain complete and accurate medical records for a resident's ADLs, with missing documentation for tasks like bladder continence and personal hygiene across multiple shifts. Staff interviews revealed issues with the documentation process, including the need to save tasks in the EMR system to prevent data loss. The Medical Records staff confirmed the incomplete records, and the Unit Manager and DON acknowledged the deficiency, citing possible unfamiliarity with the kiosk system.
Failure to Timely Assess and Intervene for Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that residents received timely assessment, monitoring, and implementation of appropriate interventions for skin integrity concerns, resulting in deficiencies for two residents. For one resident admitted with multiple stage 2 pressure injuries and bruising, documentation showed that although wounds were identified upon admission, there was a lack of timely care plan initiation and physician orders for wound care. The care plan and treatment orders were not established until several days after admission, despite the presence of significant skin issues. The Director of Nursing confirmed that there was no care plan in place upon the resident's return from the hospital and that wound care orders were not entered as required. Another resident was admitted with a history of cerebral infarction and diabetes mellitus and was found to have an open area with redness and swelling on the left thigh. Although an incident report was completed and the nurse practitioner was notified, there was a delay in documenting the skin assessment and initiating a care plan. The care plan for the wound was not started until after the resident returned from the hospital, well beyond the required timeframe. Progress notes indicated that the wound worsened, leading to a hospital transfer for surgical evaluation. The Director of Nursing acknowledged that the care plan should have been initiated within 24 hours but was not. Facility policies require a full body skin assessment on admission, timely documentation, prompt initiation of care plans, and immediate notification of providers and families for new skin impairments. However, in both cases, there were lapses in following these protocols, including delays in documentation, care plan initiation, and implementation of physician orders for wound care. These failures resulted in residents not receiving the necessary care and services to maintain their highest practicable physical well-being, as required by professional standards and facility policy.
Resident Injured Due to Unsecured Side Rail
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident #103, who sustained serious injuries due to a side rail accident. The resident, who was severely cognitively impaired with a diagnosis of Alzheimer's, was receiving care when the incident occurred. While the resident was holding onto the side rail for support, the rail fell, resulting in lacerations to two fingers on the resident's right hand, which subsequently required amputation. The incident report and interviews revealed that the side rail was not properly secured, allowing it to shake and eventually fall. A CNA was providing care on the opposite side of the bed and did not check the stability of the side rail, assuming it was secure. The CNA witnessed the resident shaking the rail but did not intervene or check its stability, leading to the accident. The nurse on duty responded to the emergency by applying first aid and calling 911, but the damage had already been done. Interviews with staff indicated a lack of consistent checks on the side rails' security, as the CNA admitted to not verifying the rail's tightness on that day. The facility's policy required maintenance to ensure side rails were secure, but there was no documentation of such checks being performed prior to the incident. The Director of Nursing, who was not in position at the time, stated that staff should have intervened when the rail was shaking and notified maintenance, highlighting a gap in protocol adherence.
Unresolved Flooring Issue in Resident's Bedroom
Penalty
Summary
The facility failed to ensure a safe and homelike environment for a resident, identified as R37, due to an unresolved flooring issue in the resident's bedroom. The problem originated from a leak in the faucet/sink, which caused water to overflow and remain on the floor, leading to the buckling of the linoleum. This issue was first noted on 11/24/24, but the facility's logbook did not record any floor problem, indicating a lack of proper documentation and follow-up on the maintenance issue. On 12/19/24, an observation revealed a significant section of missing tile in R37's bedroom, exposing concrete flooring and posing a potential safety hazard. Despite the presence of a large yellow sign indicating danger, the issue had not been addressed promptly. Interviews with the Regional Maintenance Director and the Maintenance Director confirmed the condition of the floor and the delay in repairs, as the Maintenance Director was waiting for the survey to conclude before beginning work. The facility's policy on maintenance repairs, which requires repair concerns to be logged, was not adequately followed in this instance.
Resident's Rights Violated by Unconsented Wander Guard Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R64, was free from physical restraints, specifically a wander guard, which was applied without the resident's consent. R64, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, depressive disorder, and anxiety disorder, was assessed to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite this, the facility placed a wander guard on R64 due to concerns about impulsive behavior and verbalizations of leaving the facility, although there was no documented evidence of wandering or exit-seeking behaviors. Interviews with staff revealed that the wander guard was applied as a preventive measure for R64's safety, despite the resident's cognitive awareness and lack of documented exit-seeking behavior. The Assistant Director of Nursing and Registered Nurse 2 noted that the wander guard was used as a precaution, and the Director of Nursing stated that the interdisciplinary team decided on its use for safety reasons. However, R64 expressed that she did not consent to the wander guard and felt it restricted her freedom to go outside, as she was not allowed to leave unless accompanied by staff. The facility's policy on restraints emphasizes that residents have the right to be free from physical restraints and to participate in care planning, including the right to refuse treatment. The policy also requires that the use of restraints be clinically justified and guided by evidence-based guidelines. In this case, the application of the wander guard on R64 without her consent and without documented evidence of exit-seeking behavior constitutes a deficiency in ensuring the resident's rights to freedom from physical restraints.
Inaccurate PASARR Level I Assessment for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I assessment was completed accurately for a resident, identified as R64, who was reviewed for Level I PASARR screenings. The resident was admitted with diagnoses including schizoaffective disorder, bipolar disorder, depressive disorder, and anxiety disorder. Despite these diagnoses, the PASARR Level I screen, completed by the hospital prior to admission, did not indicate any mental illness or history of psychiatric hospitalizations. This discrepancy was not identified by the facility staff, as the Admissions Director and Director of Nursing both relied on the hospital's completion of the PASARR without verifying its accuracy. The facility's policy requires that all residents be screened for PASARR in accordance with federal regulations, which includes ensuring the accuracy of the information provided. However, the Admissions Director admitted to not reviewing the PASARR for accuracy, trusting the hospital's completion, and was unaware of the inaccuracies in R64's assessment. Similarly, the Director of Nursing was not aware that the PASARR was completed inaccurately and did not ensure that staff verified its accuracy. This oversight had the potential to prevent or delay additional services for the resident that may qualify for a Level II assessment.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences, specifically regarding the avoidance of pork, which was documented in the resident's electronic medical record and meal tickets. The resident, who was cognitively intact with a BIMS score of 15, was served a meal containing pork sausage, peppers, and noodles, despite her preference for no pork. This incident was confirmed through interviews with the resident, a Certified Nurse's Aide, the Registered Dietician, and the Dietary Manager. The resident reported that she requested an alternative meal, but it was not delivered, leading to her not receiving a suitable meal option. The facility's policy on resident food preferences, which mandates the assessment and communication of individual food preferences upon admission, was not adhered to in this case. The Director of Nursing confirmed that residents' preferences should always be respected and honored. The failure to provide an alternative meal as requested by the resident had the potential to cause emotional distress and nutritional deficit, as the resident did not receive a meal that met her dietary needs and preferences.
Incomplete Documentation of Resident ADLs
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically in documenting activities of daily living (ADL) care. The electronic medical record (EMR) for the resident lacked documentation for various ADL tasks, including bladder continence, personal hygiene, and toileting, across multiple shifts and dates. This deficiency was identified through a review of the resident's documentation survey report, which showed missing entries for several days and shifts. Interviews with facility staff revealed that the Certified Nurse Aide (CNA) responsible for documenting ADLs stated that the documentation process required saving the task after selection, or the data would be lost. The Medical Records staff confirmed the incomplete documentation and noted that EMR audits were conducted monthly by an interdisciplinary team. The Unit Manager and Director of Nursing also acknowledged the lack of documentation, attributing it to possible unfamiliarity with the kiosk system used for recording ADLs. The facility's policy mandates that medical records be complete and accurately documented to reflect the resident's care and progress.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stratford Manor Rehabilitation And Care Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Livingston Post Acute Care | 0.9 mi | ★★★★★ | 21 | 0 |
| Complete Care At Summit Ridge | 1.1 mi | ★★★★★ | 3 | 0 |
| Daughters Of Israel Pleasant Valley Home | 1.2 mi | ★★★★★ | 22 | 0 |
| Inglemoor Rehabilitation And Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.