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Complaint Investigation

Alaris Health At St Marys

October 23, 2025 · Orange, NJ · 135 South Center Street
Citations 2
CMS Rating 1/5
Beds 188
Provider ID 315352
Healthcare Facility
Alaris Health At St Marys
Orange, NJ  ·  View full profile →
Inspection Summary

ALARIS HEALTH AT ST MARYS in ORANGE, NJ — inspection on October 23, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0658
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

Review of the July 2025 TAR revealed blanks for the following treatments: Turn and reposition every 2 hours every shift was blank on 7/15/25 on the 7:00 AM shift. On 10/23/25 at 10:54 AM the surveyor interviewed the Unit Manager (UM) who stated that nurses documented on the TAR each shift.

The UM further stated that the residents were turned and positioned. On 10/23/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON) who stated that the nurses documented in the TAR after completing the resident's ordered treatment.

The DON further revealed that the nurses also documented in the nursing progress notes. A review of the facility's policy Charting and Documentation Policy and Procedure with a revision date of July 2021 revealed in the Policy Interpretation and Implementation revealed that Documentation in the medical record will be objective, complete, and accurate. NJAC 8:39-3.2(a)(b)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Axia Care Center of Orange

135 South Center Street Orange, NJ 07050

SUMMARY STATEMENT OF DEFICIENCIES

positioned. On 10/23/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON), who stated, if it is not documented it is not done.

The DON further stated that both the nurses and the CNAs were responsible for completing the ADL documentation, and that it was important to document that the care was being provided as required.

The DON also reported that the Assistant Director of Nursing (ADON) and the nurse manager were responsible for auditing ADL documentation to ensure completion. A review of the Charting and Documentation Policy and Procedure with a revised date of July 2021, revealed under Policy Interpretation and Implementation 3.

Documentation in the medical record will be objective, complete and accurate. NJAC 8:39, 27.2(b), (h).

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ORANGE, NJ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALARIS HEALTH AT ST MARYS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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