Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer and contact person for privacy practices |
Inspection Report
Life Safety
Deficiencies: 0
Jun 18, 2025
Visit Reason
A Life Safety Code Survey complaint survey was conducted on 6/18/25 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 EXISTING Health Care Occupancy.
Findings
The facility was found to be in compliance with the Life Safety Code requirements for participation in Medicare/Medicaid.
Complaint Details
Complaint #: 187349; the survey was complaint-related and found the facility in compliance.
Inspection Report
Monitoring
Census: 139
Capacity: 180
Deficiencies: 0
May 10, 2024
Visit Reason
A Federal Monitoring (Focused Concern) Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on May 9-10, 2024, following a recertification survey by the New Jersey Department of Health in March 2024.
Findings
No deficiencies were cited as a result of the Federal Monitoring Survey conducted at Aristacare at Whiting.
Inspection Report
Complaint Investigation
Census: 130
Capacity: 180
Deficiencies: 13
Mar 27, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations for multiple complaint numbers.
Findings
Deficiencies were cited related to safe and homelike environment, notice requirements before transfer/discharge, encoding/transmitting resident assessments, coordination of PASARR and assessments, services meeting professional standards, RN staffing, pharmacy services and procedures, drug regimen review, drug labeling and storage, food procurement and sanitation, infection prevention and control, and life safety code compliance.
Complaint Details
Complaint numbers NJ00153397, NJ00154875, NJ00170569, NJ00156118 were investigated during the survey.
Severity Breakdown
SS=E: 5
SS=D: 6
SS=F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to maintain a comfortable and homelike environment with multiple maintenance issues in resident rooms. | SS=E |
| Facility failed to notify residents and/or representatives in writing of transfer or discharge reasons. | SS=D |
| Facility failed to electronically transmit Minimum Data Set (MDS) assessments within required timeframes. | SS=D |
| Facility failed to conduct new PASARR assessments after new psychological diagnosis. | SS=D |
| Facility failed to obtain physician orders for discharge, follow physician medication orders, and provide ordered equipment. | SS=D |
| Facility failed to ensure RN coverage for at least 8 consecutive hours 7 days a week on multiple days. | SS=E |
| Facility failed to ensure accountability of narcotic shift count logs with missing documentation and signatures. | SS=E |
| Facility failed to ensure monthly pharmacist drug regimen reviews and reporting for several residents. | SS=E |
| Facility failed to accurately label multidose medications with open dates on medication carts. | SS=D |
| Facility failed to maintain food labeling and dating protocols in the kitchen for potentially hazardous foods. | SS=F |
| Facility failed to keep dumpster area free of garbage and debris, creating unsanitary conditions. | SS=D |
| Facility failed to implement appropriate infection control precautions for a resident with a positive infection and failed to perform adequate hand hygiene. | SS=D |
| Facility failed to ensure vertical openings such as stairway exit doors had required fire exit hardware and sprinkler piping was not sealed with fire rated material. | SS=F |
Report Facts
Census: 130
Total Capacity: 180
Deficiency counts: 13
Nursing Staffing Deficiencies: 51
Narcotic shift count missing entries: 7
Food labeling violations: 6
Fire rated door deficiencies: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged need for repairs and fire door hardware issues | |
| Licensed Practical Nurse #1 | Observed administering medication incorrectly and hand hygiene deficiencies | |
| Licensed Practical Nurse #2 | Observed narcotic count log deficiencies and medication cart issues | |
| Director of Social Work | Interviewed regarding discharge notification deficiencies and PASARR reviews | |
| Director of Nursing | Provided information on staffing and quality assurance activities | |
| Infection Preventionist | Provided education and quality assurance on infection control | |
| Activities Director | Interviewed regarding lack of evening activities |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 3
Nov 30, 2023
Visit Reason
The inspection was conducted based on complaints NJ#156370 and NJ#156705 to investigate alleged deficiencies related to RN staffing and resident care documentation.
Findings
The facility was found not in substantial compliance with federal and state regulations due to failure to ensure RN coverage for at least eight consecutive hours on multiple days and failure to consistently document Activities of Daily Living (ADL) care for residents. Additionally, the facility failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey.
Complaint Details
Complaint numbers NJ#156370 and NJ#156705 triggered the investigation. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a Registered Nurse worked for at least eight consecutive hours a day for 8 of 28 days reviewed. | SS=D |
| Failure to consistently document Activities of Daily Living (ADL) status and care provided to a resident, evidenced by blank spaces on documentation forms. | SS=D |
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for multiple day, evening, and overnight shifts. | — |
Report Facts
Census: 139
Sample Size: 5
Days with no RN coverage: 8
Deficient day shifts: 27
Deficient evening shifts: 2
Deficient overnight shifts: 6
Inspection Report
Annual Inspection
Census: 133
Deficiencies: 7
Dec 6, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to medication administration, documentation of catheter output, pharmacy services, medication storage and labeling, food safety, corridor handrails, and staffing ratios. The facility failed to follow physician's orders for medication administration, maintain accurate documentation, ensure proper medication storage and labeling, maintain ice machine sanitation, and provide required staffing levels.
Severity Breakdown
SS=D: 3
SS=E: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to follow physician's orders and administer medication based on pain scale level parameters. | SS=D |
| Failed to consistently document catheter urinary output according to physician orders. | SS=E |
| Failed to ensure accurate ordering, receiving, and administration of narcotic medications and maintain proper records. | SS=E |
| Failed to store and label drugs and biologicals in accordance with professional standards and manufacturer's instructions. | SS=D |
| Failed to maintain the ice machine chute to prevent microbial growth and food borne illness. | SS=D |
| Failed to equip corridors with firmly secured handrails on each side. | SS=E |
| Failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | — |
Report Facts
Census: 133
Deficiency count: 7
Staffing ratios not met: 7
Medication administration errors: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and narcotic reconciliation findings |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and narcotic reconciliation findings |
| LPN #3 | Licensed Practical Nurse | Named in narcotic log and medication storage findings |
| LPN #4 | Licensed Practical Nurse | Named in narcotic log findings |
| Director of Nursing | Director of Nursing | Named in multiple findings and interviews |
| Food Service Director | Food Service Director | Named in ice machine sanitation findings |
| Maintenance Director | Maintenance Director | Named in ice machine sanitation and corridor handrails findings |
| Licensed Nursing Home Administrator | Administrator | Named in multiple interviews and findings |
| Regional Clinical Consultant/Registered Nurse | Regional Clinical Consultant/Registered Nurse | Named in multiple interviews and findings |
Inspection Report
Life Safety
Deficiencies: 2
Dec 6, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/06/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found noncompliant with fire safety requirements, specifically failing to provide audible and visible fire alarm notification in an enclosed courtyard and lacking proper fire sprinkler coverage in two closets. Corrective actions were planned and completed by 1/17/2022.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide fire alarm notification by audible and visible signals for one enclosed courtyard. | SS=D |
| Failed to provide proper fire sprinkler coverage in two closets (sensory room closet and telephone/cable closet). | SS=D |
Report Facts
Deficiencies cited: 2
Completion date for corrective actions: Jan 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to failure to inspect and ensure proper fire alarm and sprinkler systems | |
| Licensed Nursing Home Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 0
Oct 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ148205, NJ147584, and NJ146388.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
The survey was complaint-driven with three complaint numbers referenced: NJ148205, NJ147584, and NJ146388. The facility was found compliant.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 0
Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ138437 and NJ139903.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ138437 and NJ139903 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Jun 16, 2021
Visit Reason
The inspection was conducted based on complaint NJ146034 to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to follow a resident's care plan interventions regarding the resident's preference for female caregivers for 1 of 3 residents reviewed. Interviews and record reviews confirmed a male CNA was assigned to a resident who preferred female caregivers.
Complaint Details
Complaint NJ146034 was substantiated as the facility failed to comply with the resident's care plan preference for female caregivers.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow a resident's care plan interventions for the resident's preference for female caregivers. | SS=D |
Report Facts
Census: 124
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Assistant (CNA) | Male CNA assigned to resident preferring female caregivers; name redacted | |
| Unit Manager (UM) | Interviewed regarding resident preference for female caregivers | |
| Assistant Administrator (AA) | Interviewed regarding care plan adherence and staffing |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 2
May 27, 2021
Visit Reason
The inspection was conducted in response to complaint NJ145641 concerning allegations of sexual misconduct and failure to report abuse within the facility.
Findings
The facility failed to initiate an investigation and report allegations of sexual misconduct and inappropriate behavior involving residents to the administration, the New Jersey Department of Health, and law enforcement. The incidents resulted in psychological harm to residents and noncompliance with facility abuse policies and reporting requirements.
Complaint Details
Complaint NJ145641 involved allegations of sexual misconduct and inappropriate sexual behavior by staff and residents. The facility failed to report these allegations timely to the NJDOH and law enforcement, and failed to follow its abuse policy. The investigation found some allegations unsubstantiated but identified failures in reporting and investigation procedures.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to initiate an investigation and report an allegation of sexual misconduct to administration and appropriate authorities. | SS=G |
| Failure to report allegations of abuse and inappropriate behavior to the NJDOH and Police Department within required timeframes. | SS=D |
Report Facts
Census: 121
Sample Size: 4
Inspection Report
Routine
Census: 111
Deficiencies: 0
Dec 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 3
Nov 22, 2020
Visit Reason
The inspection was conducted based on Complaint # NJ 141277 regarding failure to protect residents from abuse and neglect, specifically related to inadequate monitoring and supervision of a resident with known inappropriate behaviors.
Findings
The facility failed to ensure consistent 1:1 monitoring of a resident with a history of inappropriate sexual behaviors due to staffing shortages, placing residents in Immediate Jeopardy. The facility also failed to post nurse staffing information timely and did not meet minimum staffing levels on one day during the week of 11/21/20.
Complaint Details
Complaint # NJ 141277 involved allegations of abuse and neglect related to failure to provide 1:1 monitoring for a resident with inappropriate sexual behaviors. The Immediate Jeopardy was identified on 11/22/20 and removed after the facility implemented a Removal Plan including staffing adjustments and monitoring changes.
Severity Breakdown
SS=J: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents were protected from abuse by not consistently monitoring a resident with known inappropriate behaviors, resulting in Immediate Jeopardy. | SS=J |
| Failure to post Nursing Staff Information/Data in a timely manner as required by facility policy. | SS=D |
| Failure to provide minimum required nurse staffing levels for 1 out of 7 days during the week of 11/21/20. | — |
Report Facts
Census: 107
Sample size: 3
Staffing shortfall hours: 9.55
Daily required staffing hours: 289.55
Actual staffing hours: 280
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Notified of Immediate Jeopardy situation on 11/22/20 | |
| Director of Nursing (DON) | Notified of Immediate Jeopardy, involved in staffing and monitoring discussions | |
| Licensed Practical Nurse (LPN #1) | Reported staffing shortage and inability to provide 1:1 monitoring on 11/21/20 | |
| Unit Manager (UM) | Reported monitoring practices for resident | |
| Shift Supervisor | Aware of staffing shortage and monitoring issues on 11/21/20 | |
| Staffing Coordinator | Reported staffing call outs and weekend staffing challenges | |
| Receptionist | Responsible for posting staffing sheets but unaware of weekend posting responsibility |
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