Inspection Reports for
Aristacare At Whiting

Complaint #2563750 involved failure to develop and implement a care plan for Resident #14 and medication administration errors for Residents #144 and #27. The complaint was substantiated based on interviews, record reviews, and observations.

The facility failed to develop and implement a complete care plan for Resident #14, specifically regarding the use of a stop sign on the resident's door. Additionally, the facility failed to administer medications within the prescribed time frame for Residents #144 and #27, resulting in medication administration errors.

The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, inadequate behavior monitoring for psychotropic medication use, inaccurate resident assessments, incomplete care plans, unsafe use of portable electric heaters posing immediate jeopardy, failure to follow respiratory equipment policies, lack of required RN staffing hours, medication administration errors with late dosing, unsafe food handling and sanitation practices, inadequate infection control for respiratory equipment, and malfunctioning resident call bell systems.

The visit was complaint-driven based on complaints NJ152908, NJ156248, and NJ152672. The investigation substantiated multiple deficiencies including environmental hazards, failure to notify residents and representatives of hospital transfers, failure to update PASRR assessments, and insufficient RN staffing.

The facility was found deficient in maintaining a homelike environment with multiple environmental hazards and maintenance issues, failure to notify residents and representatives in writing about hospital transfers for 3 residents, failure to conduct updated PASRR assessments after new mental health diagnoses, and failure to ensure RN coverage 7 days a week for at least 8 consecutive hours for 5 of 51 days reviewed. All deficiencies were cited with minimal harm or potential for actual harm.

Complaint numbers NJ00153397, NJ00154875, NJ00170569, NJ00156118 were investigated during the survey.

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.

The visit was complaint-related based on complaints NJ152908, NJ156248, and NJ152672 regarding environmental conditions, notification failures, assessment and medication errors, staffing, and infection control.

The facility was found deficient in multiple areas including environmental maintenance issues in resident rooms, failure to notify residents and representatives of hospital transfers in writing, late transmission of MDS assessments, failure to update PASRR assessments after new mental health diagnoses, failure to obtain physician discharge orders and follow medication orders, inadequate nurse staffing with RN coverage gaps, incomplete narcotic shift counts, failure to ensure monthly consultant pharmacist reviews, improper medication labeling and storage, food labeling and sanitation violations, failure to maintain dumpster area cleanliness, and failure to implement proper infection control precautions and hand hygiene.

Complaint # NJ#156705 related to RN staffing shortages and Complaint # NJ#156370 related to failure to document ADL care. Both complaints were substantiated with findings of minimal harm affecting a few residents.

The facility failed to ensure a Registered Nurse was on duty for at least eight consecutive hours on multiple days and failed to consistently document ADL care provided to Resident #4, with multiple blank entries on care documentation forms.

Complaint numbers NJ#156370 and NJ#156705 triggered the investigation. The facility was found not in substantial compliance based on these complaints.

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.

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.

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.

The facility was found deficient in multiple areas including failure to follow physician's orders for pain medication administration, inconsistent documentation of urinary catheter output, inaccuracies in narcotic medication ordering and documentation, improper storage and labeling of medications, inadequate cleaning of the ice machine leading to potential microbial contamination, and lack of firmly secured handrails in corridors on the second floor.

Complaint NJ146034 was substantiated as the facility failed to comply with the resident's care plan preference for female caregivers.

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 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.

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 # 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.

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.