Cycle 1
Health 2024-12-19 · Fire 2024-12-19
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
West Orange, NJ
Alaris Health At West Orange
3-star overall rating with 2-star inspections with $18,000 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5 Brook End Drive, West Orange, NJ
(973) 324-3000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Alaris Health
Operator or chain grouping
Approved since
1998-09-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.77
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,542
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9969
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.95
Baseline 19.79% · Performance 20.99% · Measure score 0.95 · Achievement 0.95 · Improvement 0
Healthcare-associated infections
7.65
Baseline 6.50% · Performance 5.55% · Measure score 7.65 · Achievement 7.65 · Improvement 5.83
Total nurse turnover
3.99
Baseline 39.33% · Performance 47.37% · Measure score 3.99 · Achievement 3.99 · Improvement 0
Adjusted total nurse staffing
4.94
Baseline 3.70 hours · Performance 4.48 hours · Measure score 4.94 · Achievement 4.94 · Improvement 3.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 9.59% · Lower 95% interval 6.84% |
| Discharge to community | 51.48% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 40.6% · Lower 95% interval 43.67% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 76 · Denominator 76 |
| Falls with major injury | 1.32% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 76 |
| Discharge self-care score | 57.41% |
53.69%
3.7 pts better
|
Numerator 31 · Denominator 54 |
| Discharge mobility score | 55.56% |
50.94%
4.6 pts better
|
Numerator 30 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 4 · Denominator 76 · Adjusted rate 4.58% |
| Healthcare-associated infections requiring hospitalization | 5.55% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 3.33% · Lower 95% interval 3.01% |
| Staff COVID-19 vaccination coverage | 1.45% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 138 |
| Staff flu vaccination coverage | 98.63% |
42%
56.6 pts better
|
Numerator 144 · Denominator 146 |
| Discharge function score | 57.41% |
56.45%
1 pts better
|
Numerator 31 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 34.38% |
25.2%
9.2 pts better
|
Numerator 11 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.1
0.6 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
93.0%
6.4 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.4%
1.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 1.2% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
11.4%
11.1 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
4.6%
2.1 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.9% · Q3 7.9% · Q4 7.1% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.4% |
19.0%
12.6 pts better
|
19.6%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.5% · Q3 7.7% · Q4 5.9% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
13.5%
5.1 pts better
|
16.7%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 10.9% · Q3 5.1% · Q4 6.2% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.6% |
9.8%
0.8 pts worse
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 11.5% · Q3 7.7% · Q4 4.3% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
9.7%
1.7 pts worse
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 11.7% · Q3 5.5% · Q4 9.1% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.7%
0.3 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.8% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
0.8%
1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 3.7% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.0% |
15.9%
9.9 pts better
|
19.8%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.0% · Q3 2.5% · Q4 11.0% · 4Q avg 6.0% |
| Percentage of long-stay residents with pressure ulcers | 11.9% |
6.0%
5.9 pts worse
|
5.1%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 15.9% · Q3 13.8% · Q4 11.1% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
78.7%
19.2 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 98.2% · Q3 99.2% · Q4 96.9% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.0% |
8.2%
5.2 pts better
|
12.0%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 3.1% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.4% |
80.1%
17.3 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
25.4%
2.4 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 29.7% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-12 · Fire 2022-08-12
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-01-15 · Fire 2020-01-15
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-01-21
F · Potential for more than minimal harm
2024-12-19
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-21
F · Potential for more than minimal harm
2022-08-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-08-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-08-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-29
F · Potential for more than minimal harm
2022-08-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-08-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-08-12
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-08-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-09
D · Potential for more than minimal harm
2020-01-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-02-07
D · Potential for more than minimal harm
2020-01-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-07
D · Potential for more than minimal harm
2020-01-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-02-07
Inspection history
Recent health citations
G · Actual harm
2025-12-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-06
G · Actual harm
2024-12-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-21
K · Immediate jeopardy
2022-08-12
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-09
E · Potential for more than minimal harm
2020-01-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-02-07
D · Potential for more than minimal harm
2020-01-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-02-07
D · Potential for more than minimal harm
2020-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-07
D · Potential for more than minimal harm
2020-01-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-02-07
Penalties and ownership
What sits behind the stars
$18,000
2024-12-19
Fine
Fine · fine $18,000
Fine
Ownership
Eisenreich, Avery
5% Or Greater Direct Ownership Interest · Individual
Giles, Kristine
W-2 Managing Employee · Individual
St Cloud Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, Samuel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Stratford Manor Rehabilitation And Care Center
West Orange, NJ
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Livingston Post Acute Care
Livingston, NJ
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Complete Care At Summit Ridge
West Orange, NJ
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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