Cycle 1
Health 2025-01-23 · Fire 2025-01-23
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Orange, NJ
Axia Care Center of Orange
1-star overall rating with 1-star inspections with $124,800 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
135 South Center Street, Orange, NJ
(973) 266-3000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
188
Certified beds
Average residents
163
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Alaris Health
Operator or chain grouping
Approved since
1996-02-08
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
1.13
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
74%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,079
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.61
Baseline 21.40% · Performance 19.29% · Measure score 4.61 · Achievement 4.61 · Improvement 4.31
Healthcare-associated infections
2.87
Baseline 6.40% · Performance 6.98% · Measure score 2.87 · Achievement 2.87 · Improvement 0
Total nurse turnover
3.35
Baseline 26.87% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
2.80
Baseline 3.58 hours · Performance 3.88 hours · Measure score 2.80 · Achievement 2.80 · Improvement 0.85
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.06% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 21.43% · Lower 95% interval 9.03% |
| Discharge to community | 50.1% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 32.31% · Lower 95% interval 37.16% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.29% |
95.27%
4 pts better
|
Numerator 140 · Denominator 141 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 141 |
| Discharge self-care score | 48.19% |
53.69%
5.5 pts worse
|
Numerator 40 · Denominator 83 |
| Discharge mobility score | 42.17% |
50.94%
8.8 pts worse
|
Numerator 35 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 4 · Denominator 140 · Adjusted rate 1.96% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 9.84% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 2 · Denominator 255 |
| Staff flu vaccination coverage | 96.15% |
42%
54.2 pts better
|
Numerator 275 · Denominator 286 |
| Discharge function score | 46.99% |
56.45%
9.5 pts worse
|
Numerator 39 · Denominator 83 |
| Transfer of health information to provider | 98.25% |
95.95%
2.3 pts better
|
Numerator 56 · Denominator 57 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 44 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 18 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.4 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.1
0.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
93.0%
4.1 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 97.9% · Q3 97.9% · Q4 94.4% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
97.2%
0.8 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.4%
1.9 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 0.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.4%
11.4 pts better
|
11.4%
11.4 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 who lose too much weight | 2.5% |
4.6%
2.1 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.0% · Q3 2.3% · Q4 1.5% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
19.0%
5.4 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 13.0% · Q3 15.2% · Q4 15.8% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
13.5%
2 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 12.2% · Q3 12.9% · Q4 11.1% · 4Q avg 11.5% · 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 | 10.4% |
9.8%
0.6 pts worse
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 13.5% · Q3 4.2% · Q4 5.4% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
9.7%
0.5 pts worse
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 12.1% · Q3 7.3% · Q4 9.6% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.4% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.2% |
15.9%
4.7 pts better
|
19.8%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 13.4% · Q3 13.0% · Q4 9.6% · 4Q avg 11.2% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
6.0%
5.4 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 13.5% · Q3 13.4% · Q4 10.3% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.8% |
78.7%
8.9 pts worse
|
81.7%
11.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.8% · Q2 68.8% · Q3 60.0% · Q4 73.6% · 4Q avg 69.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
8.2%
2 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.9% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.2% |
80.1%
13.9 pts worse
|
79.7%
13.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
25.4%
3.1 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 34.3% · Expected 28.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-18 · Fire 2023-09-18
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-01-13 · Fire 2022-01-13
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-26
F · Potential for more than minimal harm
2023-09-18
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-10-23
F · Potential for more than minimal harm
2023-09-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-17
D · Potential for more than minimal harm
2022-01-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-01-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-10-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-04-15
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-15
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-05-07
L · Immediate jeopardy
2025-01-23
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 2025-02-26
G · Actual harm
2025-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-23
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-23
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-23
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-02-26
E · Potential for more than minimal harm
2025-01-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-26
E · Potential for more than minimal harm
2025-01-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-26
E · Potential for more than minimal harm
2025-01-23
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-23
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 2025-02-26
D · Potential for more than minimal harm
2025-01-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-23
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-26
E · Potential for more than minimal harm
2023-09-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-09-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-09-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-09-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-25
F · Potential for more than minimal harm
2022-01-13
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2022-01-25
D · Potential for more than minimal harm
2022-01-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-01-25
D · Potential for more than minimal harm
2022-01-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-01-20
D · Potential for more than minimal harm
2022-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-21
Penalties and ownership
What sits behind the stars
$124,800
2025-01-23
Fine
Fine · fine $124,800
Fine
Ownership
Domingo, Margot
W-2 Managing Employee · Individual
South Center Street Nursing LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, Samuel
Corporate Officer · Individual
Zelmanovitz, Joseph
5% Or Greater Direct Ownership Interest · Individual
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#3
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