Aristacare at Whiting

Inspectors wroteBased on observation, interview, and documentation review, it was determined that the facility failed to prohibit the use of portable electric space heaters in an unsafe manner and in accordance with product fire safety guidelines to maintain a safe environment free of fire hazards in accordance with CFR 483.25(d). This deficient practice affected all 127 residents residing at the facility and was evidenced by the following:Observations on 08/12/2025 at 10:35 AM, in the presence of the Maintenance Director (MD) and Regional Director of Maintenance (RDM), revealed a portable electric space heater that was plugged into an unapproved electrical adapter, was ON and unattended under the wood desk next to combustible storage in the second floor Social Worker (SW) office. [...]

Inspectors wroteComplaint NJ #: 182491 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 9 of 9 days reviewed. This deficient practice was evidenced by the following: Review of the PBJ Staffing Data Report for Quarter 2 2025 (January 1 - March 31) revealed the facility had no Registered Nurse (RN) hours for the following dates:01/05/202501/19/202502/15/202502/22/202502/23/202503/01/202503/08/202503/15/2025Review of the Employee Daily Schedule by Shift, provided by the facility, for the aforementioned dates verified that there was no RN scheduled to work 8 consecutive hours. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness and b.) maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 8/8/25 at 9:18 AM, the surveyor toured the kitchen with the Assistant Food Service Director (AFSD) and observed the following: 1. At the time of observation, the dish machine was not running. The surveyor requested to view the logs of temperature checks. Log review showed no temp check for 8/6/25, 8/7/25, and 8/8/25 for the AM. The AFSD stated, They didn't do them. 22. On a large metal rack there were items that the AFSD said were drying. [...]

Inspectors wroteBased on observation, interview, and review of facility documents it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. The deficient practice was identified for 2 of 3 Units identified under the Environmental Task. The deficient practice was evidenced by the following: On 08/11/2025 at 08:59 AM during rounds on the 2 East unit, the surveyors observed: 1. Scratches in the wall with missing paint behind the bed in room [ROOM NUMBER]. 2. A missing tile on the floor near the resident's bed in room [ROOM NUMBER]. 3. A broken bottom drawer of a dresser in room [ROOM NUMBER]. 4. A broken outlet plate with sharp edges in room [ROOM NUMBER] 5. Broken blinds in rooms [ROOM NUMBERS]. 6. A broken middle drawer to the nightstand in room [ROOM NUMBER]. 7. Cracked and missing foam from the handle of the reclining chair in room [ROOM NUMBER]. 8. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation it was determined the facility failed to provide adequate behavior monitoring for a resident receiving psychotropic medications. This deficient practice was identified in 1 of 5 residents reviewed for unnecessary medication (Resident #12) and was evidenced by the following:On 8/8/25 at 10:10 AM, the resident was observed self-propelling in a wheelchair in the room. The surveyor reviewed Resident #12 medical record. A review of the admission Record revealed Resident #12 was admitted with medical diagnoses which included but were not limited to schizoaffective disorder (combination of schizophrenia and mood disorder), depression, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and pain in right hip. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 25 residents reviewed, Resident #10. This deficient practice was evidenced by the following:The surveyor reviewed the admission Record for Resident #10 which reflected that the resident was admitted with diagnoses that included hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (high blood pressure with severe kidney damage where the kidneys have almost completely stopped working) and essential Primary hypertension (high blood pressure.)The surveyor reviewed the physician's orders revised on 7/17/2025 which revealed Hemo-dialysis M-W-F send patient with Dialysis binder fill out vital signs and medications given prior to leaving. [...]

Inspectors wrotecomplaint # 2563750Based on interview and record review, it was determined that the facility failed to develop and implement a care plan that meets the needs identified on the comprehensive assessment care for 1 of 25 residents reviewed for comprehensive care plans, Resident #14. This deficient practice was evidenced by the following:On 08/08/2025 at 09:37 AM during initial tour of the facility the surveyor observed Resident # 14 in bed with the door to their room open. There was a mesh stop sign attached to one side of the door and not connected to the other side. On 08/11/2025 at 09:11 AM the surveyor observed Resident # 14 sitting on their bed with the door open, the mesh stop sign was not connected to both sides of the door. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for respiratory equipment. This deficient practice was identified for 1 of 3 (Resident #3) residents reviewed for respiratory concerns and was evidenced by the following: During a tour of the facility on 08/08/2025 at 9:49 AM, Resident #3 was observed in the room. The surveyor observed the nebulizer machine (a nebulizer machine delivers aerosol medication to the person via a mouthpiece) on a cabinet next to the resident's bed. The surveyor observed the tubing dated 07/31/2025. On 08/11/2025 at 8:38 AM, the surveyor observed the tubing of the nebulizer machine dated 07/31/2025. A review of the medical record revealed Resident # 3 had diagnoses that included but were not limited to respiratory failure and asthma. [...]

Inspectors wroteNJ00182491, NJ00182879 NJ00186106Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 2 of 2 residents (Resident #144, and #27) reviewed and was evidenced by the following: Complainant stated pain medications ordered nightly were given late. The surveyor reviewed the resident’s medical records. Review of the admission Records indicated Resident #144 was admitted to the facility with medical diagnoses that included but were not limited to fracture of left humerus (arm), congestive heart failure and depression. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to implement appropriate infection control for respiratory equipment. The deficient practice was identified for 2 of 2 residents (Residents # 1, 149) reviewed for Respiratory Care. The deficient practice was evidenced by the following:On 08/08/2025 at 10:06 AM during the initial tour in Resident # 149's room, the surveyor observed a nebulizer chamber (piece of a small machine that turns liquid medicine into a mist that can be easily inhaled) disassembled and drying adjacent to a worn pair of socks on top of the nightstand. The tube for the nebulizer was on top of the socks. [...]

Inspectors wroteBased on observations, documentation review, and interviews on 8/12/2025 and 8/13/2025 in the presence of the Regional Director of Maintenance (RDM) and the Maintenance Director (MD), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning in accordance with State Operations Manual (SOM) Appendix PP Subsection 483.90(g). This deficient practice had the potential to affect all residents and was evidenced by the following:An observation on 08/12/2025 at 10:05 AM revealed the call station pull cord closest to the toilet in room [ROOM NUMBER] was wrapped around the grab bar, prohibiting the station from being activated. When the cord was unwrapped and tested, it failed to initiate a call. The call station for Bed A in the same room did not function when activated. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 03/18/2024 from 9:18 AM to 9:45 AM, the surveyor, accompanied by the Food Service Director (FSD), toured the kitchen and observed the following: In the walk-in freezer, the surveyor observed a spinach quiche, two packages identified by the FSD as pulled pork, and a pie with no labels or dates. The FSD stated that there should be a use by label if out of the package. He further stated that the above referenced items were not correct. [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined the facility failed to maintain a comfortable and homelike environment for resident rooms on 3 of 3 nursing units of the facility observed (1 East, 2 East, and 2 West). The evidence of this deficient practice includes: 1.) On 03/18/2024 from 9:33 AM to 11:41 AM, during the initial tour of the 2 [NAME] nursing unit, the surveyor made the following observations: The vinyl wall covering in resident room [ROOM NUMBER] behind bed B was partially removed and pulled away falling off the wall. room [ROOM NUMBER] the plastic/vinyl wall bumper behind bed A was broken with pointed edges. The bath tub in room [ROOM NUMBER] contained brown and grey stains and the overflow plate was covered with a white crusty material. [...]

Inspectors wroteBased on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 5 of 51 days reviewed under the Sufficient and Competent Nurse Staffing Task. The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 07/10/2022 through 07/16/2022, 01/08/2023 through 01/14/2023, 03/10/2024 through 03/16/2024 revealed the facility had no RN coverage for all shifts on 07/16/2022, 01/08/2023, 01/14/2023, 03/10/2024, and 03/16/2024. A review of the facility provided schedules for those dates did not reveal any RN coverage. Additionally, facility provided schedules for 07/17/2022 and 03/17/2024. 07/17/2022 did not reveal any RN coverage. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the accountability of the narcotic shift count logs were completed in accordance with facility policy. The deficient practice was identified on 2 of 4 medication carts reviewed (1 East Low side cart and 2 [NAME] High side cart) during the Medication Storage Task. The deficient practice was evidenced by the following: On 03/19/2024 at 10:05 AM during an interview with the surveyor, Licensed Practical Nurse (LPN) # 4 said that narcotic shift count logs are to be completed by two nurses (the incoming and outgoing nurses) at the same time once they confirm an accurate count of the narcotics (opium, opium derivatives, and their semi-synthetic substitutes) in the medication cart. She also confirmed that shift count logs should not be missing any documentation or signatures. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure required monthly visits by the Consultant Pharmacist (CP) for the months of November 2023, December 2023, and January 2024. This irregularity was identified for 3 of 3 residents reviewed for CP review, Residents #63, #83, and #27. This deficient practice was evidenced by the following: 1.) On 03/21/24 at 11:37 AM, the surveyor reviewed the CP progress notes. During review it was identified that the CP reviewed Resident #63 medications January 2023 through October 2023 every month. There was no available documentation for November 2023, December 2023, or January 2024. A review of the admission Record for Resident #63 indicated the resident had medical diagnoses which included but were not limited to hypertension (high blood pressure), anxiety disorder, and intellectual disabilities. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to notify the resident and/or resident representative in writing of the reason for transfer or discharge to the hospital for 3 of 3 residents reviewed for hospitalization Residents #43, #129, and #230. This deficient practice was evidenced by the following: 1.) On 03/20/24 the surveyor reviewed the Electronic Medical Record (EMR) which indicated Resident #129 was admitted to the facility for short term rehabilitation. Further review showed there was a Discharge/Return Anticipated Minimum Data Set (MDS), an assessment tool completed on 12/22/23 following a transfer to the hospital for right shoulder pain. Review of the admission Record indicated Resident #129 had medical diagnoses which included but were not limited to the following: acute respiratory failure, kidney disease, and anxiety. [...]

Inspectors wroteBased on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of completing the resident's assessment. This deficient practice was identified for 1 of 1 unsampled resident, (Resident # 95) reviewed in the Resident Assessment Task for MDS record over 120 days old. On 03/20/2024 the surveyor reviewed the MDS history in the electronic medical record which revealed: Resident #95 was discharged on 10/26/2023. Resident #95's discharge MDS was completed on 12/27/2023. The history indicates that Resident #95's discharge MDS was transmitted on 03/18/2024. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 3 residents reviewed for PASRRs (Resident #71) and was evidenced by the following: On 03/19/2024 the surveyor reviewed Resident #71's Electronic Medical Record (EMR) which included review of the PASARR level 1 completed on 08/09/2022 which was negative and marked no for any diagnoses of mental illness. Review of the admission Minimum Data Set (MDS), an assessment tool, dated 07/06/2022, indicated a Brief Interview of Mental Status (BIMS) score of 15/15, indicating intact cognition and review of section I did not include any psychiatric diagnoses. [...]

Inspectors wroteBased on observations, interview, and review of facility documentation it was determined that the facility failed to 1. Obtain physician orders for a resident's discharge home, 2. follow physicians' orders during medication observation and 3. follow physician orders by obtaining an air mattress for a resident at risk for pressure ulcers. This deficient practice was identified for 3 of 29 residents reviewed (Resident #61, #96 and #128) and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to accurately label multidose medications to facilitate the consideration of precautions and safe administration. The deficient practice was observed for 1 of 4 medication carts (2 [NAME] High Side) reviewed under the Medication and Storage Task. The deficient practice was evidenced by the following: On 03/19/2024 at 10:33 AM, the surveyor in the presence of Licensed Practical Nurse (LPN) # 2 observed the 2 [NAME] High Side medication cart. At that time, the surveyor observed the following: 1 opened Artificial Tear bottle. The bottle was not dated when it was opened. 1 opened Spiriva (treats asthma and chronic obstructive pulmonary disease) handheld inhaler. The inhaler was not dated when it was opened. 3 opened Lantaprost 0.005% ophthalmic solution eye drops. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 03/18/2024 during initial kitchen tour with the Food Service Director (FSD), the surveyor observed debris and trash around the dumpster area. The FSD stated that housekeeping was responsible for this area. He also stated that it was Monday and he guessed nobody had gotten out there as of that time. On 03/21/2024 at 12:28 PM the surveyor noted debris and trash in the area behind the dumpster area. On 03/25/2024 at 12:44 PM the surveyor interviewed the Director of Housekeeping who stated that housekeeping, maintenance and the kitchen are all in charge of the parking lot. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to 1.) implement appropriate transmission-based precautions specifically by applying precautions to a room that contained a resident with a potentially infectious disease for 1 of 1 resident (Resident #6) and 2.) failed to perform effective hand hygiene for a minimum of twenty seconds. The deficient practices were identified for 1 of 1 resident (Resident # 6) reviewed for Transmission-Based Precautions under the Infection Control task and 2 of 3 nurses observed during the Medication Administration task . The deficient practices were evidenced by the following: 1.) A review of Resident # 6's admission Record located in the Electronic Medical Record (EMR) revealed that on 03/18/2024, he/she was diagnosed with unspecified diarrhea. [...]

Inspectors wroteComplaint # NJ#156705 Based on interview and review of facility documents on 11/30/23, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 8 of 28 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Reports completed by the facility for the weeks of 07/17/22 through 07/23/22, 07/31/22 through 08/06/22, 11/12/23 through 11/18/23 and 11/19/23 through 11/25/23, revealed that the facility had no RN coverage for all shifts on 07/17/22, 07/31/22, 08/02/22, 08/03/22, 08/06/22, 11/18/23, 11/19/23 and 11/24/23. During a telephone interview with the surveyor on 12/01/23 at 11:00 am, the surveyor inquired about RN staffing in the building. The Licensed Nursing Home Administrator (LNHA) stated, Yes, there should be at least one RN in the building. [...]

Inspectors wroteComplaint #: NJ#156370 Based on interviews, medical record review, and review of other pertinent facility documents on 11/30/23, it was determined that the facility staff failed to consistently document on the Point of Care (POC) Legend Report the Activities of Daily Living (ADL) status and care provided to a resident. The deficient practice was identified for Resident #4, 1 of 5 residents reviewed for documentation and was evidenced by the following: The surveyor reviewed the closed record for Resident #4: According to the admission Record, Resident #4 was admitted on [DATE], with medical diagnoses that included but were not limited to: lack of coordination, abnormalities of gait and mobility, seizures, and depression. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to consistently document catheter urinary output according to the physician orders. This deficient practice was identified for 1 of 1 resident reviewed for urinary catheters (Resident #11) and was evidenced as follows: On 11/23/21 at 10:15 AM, the surveyor observed Resident #11 lying in bed. The resident stated he/she had a urinary catheter bag (used to empty the bladder and collect urine in a drainage bag) and that staff would empty it, but he/she would also have to remind the staff to empty his/her urinary catheter bag when necessary. The surveyor reviewed the medical record for Resident #11. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in March 2018, with diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a.) an accurate ordering, receiving and administration of narcotic medications that required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate reconciliation; b.) accurately document the administration of controlled medications; c.) ensure Narcotic Shift Count logs were completed in accordance with facility policy; and d.) maintain a system of record keeping that ensures an accurate inventory of controlled medications. This deficient practice was identified for 5 of 7 DEA 222 forms reviewed and 3 of 4 medication carts reviewed. The evidenced was as follows: [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that corridors were equipped with firmly secured handrails on each side. The deficient practice was identified on 1 of 3 nursing units (Second Floor) and evidenced by the following: On 12/6/21 beginning at 8:25 AM, the surveyor in the presence of the facility's Maintenance Director (MD) toured the Second Floor nursing unit (Memory Impaired Unit). During the tour, the surveyor observed three (3) areas in the corridors that had no hand rails for residents to utilize in the following locations: 1. At 9:01 AM, the surveyor observed next to Resident room [ROOM NUMBER] a six (6) feet long section of corridor wall with no handrail and across by stairwell #5 was a three (3) feet long section of wall with no handrail. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to follow physician's orders and administer medication based on pain scale level parameters for the prescribed medication oxycodone (a medication to treat severe pain) in accordance with professional standards of practice. The deficient practice was identified for 1 of 4 residents (Resident #115) reviewed for pain management. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards and manufacturer's instructions. This deficient practice was identified for 3 of 4 medication carts and 1 of 2 mediation rooms inspected and was evidenced by the following: 1. On 11/29/21 at 8:41 AM, the surveyor in the presence of the Registered Nurse/ Infection Preventionist (RN/IP) observed Nursing Unit 2 West's medication storage room. The medication refrigerator in the storage room contained one open multidose vial of Flucelvax (an injectable flu vaccine medication). The medication box was dated 11/5/21, the medication vial was not dated when it was opened. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation it was determined the facility failed to maintain the ice machine chute to prevent microbial growth and food borne illness. This deficient practice was identified in the main kitchen and was evidenced by the following: On 11/22/21 at 09:55 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD). The surveyor asked to see the cleaning log for the ice machine and who was responsible to clean and maintain the ice machine. The FSD replied that he cleaned it, and maintenance sometimes cleaned. The surveyor reviewed the cleaning log which indicated that the last date the ice machine was cleaned was 8/16/21. Prior to 8/16/21, the log was signed as cleaned monthly from January 2021 to August 2021. [...]