16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
West Orange, NJ
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
103 Pleasant Valley Way, West Orange, NJ
(973) 731-2300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
127
Certified beds
Average residents
95
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.48
Registered nurse staffing
LPN hours / resident day
1.13
Licensed practical nurse staffing
Aide hours / resident day
2.27
Nurse aide staffing
Weekend hours
3.62
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.1
0.6 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
93.0%
21.4 pts worse
|
93.4%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
97.2%
3 pts worse
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.4%
1.4 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
11.4%
3.1 pts better
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.4% |
4.6%
0.8 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
19.0%
10.8 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
13.5%
6.6 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.1% |
9.8%
1.7 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
9.7%
3.9 pts worse
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
15.9%
13.5 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
6.0%
3.1 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.8% |
78.7%
21.9 pts worse
|
81.7%
24.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
8.2%
0.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.9% |
80.1%
8.2 pts worse
|
79.7%
7.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
Survey summary
Top issue: Resident Assessment and Care Planning (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
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 2025-02-25
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 2025-02-25
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 2025-02-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-25
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-25
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-25
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-04-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-25
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-22
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-03-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-14
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-03-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-27
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-27
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 2025-11-18
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-27
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-11-27
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-03-24
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-03-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-24
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-24
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-24
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-24
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-03-24
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-24
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-27
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-27
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-27
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-23
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-03-31
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-03-31
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2021-03-31
Penalties and ownership
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Nearby options
Caldwell, NJ
2-star overall rating with 3-star inspections with $16,171 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Montclair, NJ
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Montclair, NJ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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