St Mary's Nursing Home Safety Violations - Orange NJ
ORANGE, NJ - A January 2025 state inspection of Alaris Health at St Mary's uncovered serious safety violations including improper handling of dangerous materials in resident rooms, inadequate supervision during medical transfers, and systemic failures in quality assurance programs that put vulnerable residents at risk.
Dangerous Materials Found in Oxygen-Rich Environment
Inspectors discovered a particularly alarming situation involving Resident #143, who was repeatedly found with cigars and smoking materials in their room despite having piped-in oxygen. During the three-day inspection period from January 15-17, 2025, surveyors observed the resident with cigars within arm's reach on multiple occasions.
"I buy my own cigars. I walk to the store," the resident told inspectors when questioned about the materials. When asked about a lighter, the resident gestured toward their nightstand and stated they had put it away, though they couldn't locate it when requested.
The resident's room displayed clear "No Smoking" signage with warnings about piped-in oxygen use. A registered nurse explained that residents were prohibited from smoking in their rooms due to fire risks, especially with oxygen present, and that smoking supplies should be confiscated and stored securely when violations occurred.
This combination of smoking materials and supplemental oxygen creates an extremely hazardous fire risk. Oxygen significantly increases combustion rates and fire intensity, making even small ignition sources potentially catastrophic. The presence of combustible materials in oxygen-enriched environments violates fundamental fire safety protocols and puts not only the individual resident but the entire facility at risk.
Serious Transfer Incident Raises Safety Concerns
The inspection revealed troubling details about an incident involving Resident #264, a ventilator-dependent patient in a persistent vegetative state who sustained a traumatic eye injury during a mechanical lift transfer. The resident required hospitalization and CT scans to rule out fractures after developing significant bruising and swelling around the right eye.
Investigation documents showed conflicting accounts from the staff member who performed the transfer. The aide initially reported finding the resident with a black eye in the afternoon, but later provided a second statement claiming the injury was noticed after a mechanical lift transfer. During interviews, the aide admitted that "another co-worker coached her to write the second statement" and that she "did not observe any injury to the resident face and right eye while the resident was sitting in the chair."
Facility protocols required two staff members to be present for all mechanical lift transfers of ventilator-dependent residents - one nurse and one aide, or a respiratory therapist when a nurse was unavailable. However, investigation revealed the transfer was performed by a single aide without proper supervision.
"Some CNAs worked as floaters to the unit and they were not trained to transfer residents with the ventilator attached," a respiratory therapist explained to inspectors. "For safety reasons, a nurse had to be in the room to assist."
The lack of proper supervision during transfers of critically dependent residents represents a significant breach of safety protocols. Ventilator-dependent patients require specialized handling due to their complex medical equipment and inability to protect themselves during movement. Without adequate supervision, these vulnerable individuals face increased risks of injury from improper positioning, equipment displacement, or transfer accidents.
Substance Abuse Incidents Highlight Monitoring Failures
The facility documented multiple incidents involving Resident #34, who repeatedly tested positive for illegal substances despite being enrolled in a methadone treatment program. Between July and December 2024, the resident tested positive for cocaine, opiates, and morphine on multiple occasions and was found with drug paraphernalia including glass pipes, vape pens, and lighters.
Progress notes revealed the resident was observed "going to the fence in the smoking courtyard" and receiving items from individuals outside the facility. Staff discovered homemade drug paraphernalia hidden under the resident's bed and documented erratic behavior consistent with substance use.
Despite these repeated incidents, monitoring appeared inconsistent. While the facility implemented periodic room searches and temporary one-on-one supervision, these measures failed to prevent continued access to illegal substances. The Medical Director stated he was unaware of these incidents and indicated such behavior warranted serious consequences, including potential discharge due to fire safety risks.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AXIA CARE CENTER OF ORANGE in ORANGE, NJ was cited for violations during a health inspection on January 23, 2025.
During the three-day inspection period from January 15-17, 2025, surveyors observed the resident with cigars within arm's reach on multiple occasions.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.