Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aristacare At Whiting during CMS and state inspections, most recent first.
A resident with bipolar disorder, dementia, and anxiety disorder was observed multiple times without a required mesh stop sign across their door, an intervention specified in their care plan to prevent others from entering the room. Staff interviews confirmed the care plan was not being followed, despite facility policy and expectations for adherence.
Two residents with pain management needs received their prescribed narcotic medications outside the required administration window on multiple occasions. Nursing staff confirmed that medications should be given within one hour of the scheduled time, but audit reports showed repeated late administrations, contrary to facility policy and prescriber's orders.
A survey identified deficiencies in food handling and sanitation practices. Items in the walk-in freezer, including a spinach quiche, pulled pork, and a pie, were found without proper labeling and dates. The Food Service Director confirmed the absence of required use-by labels, which is against the facility's policy on labeling and dating food items.
The facility failed to maintain a comfortable and homelike environment across three nursing units, with issues such as damaged walls, broken furniture, missing floor tiles, and stained bathtubs. The Director of Maintenance acknowledged the need for repairs but was unaware of some issues until pointed out by surveyors.
The facility failed to ensure an RN worked 7 days a week for at least 8 consecutive hours a day on multiple occasions. Specific dates lacked RN coverage, and although the DON was present on one date, the resident census was 136. The DON acknowledged that RNs sometimes leave for various reasons.
The facility failed to ensure the accountability of narcotic shift count logs, as required by its policy. Multiple instances of incomplete documentation and missing signatures were found on two medication carts. Interviews with staff and the DON confirmed that the logs should be completed by two nurses together at the end of each shift, but this procedure was not consistently followed.
The facility failed to ensure required monthly visits by the Consultant Pharmacist for three months, affecting three residents with various medical conditions. The DON confirmed the absence of the CP and stated that medication passes were conducted by nurses during this period.
The facility failed to notify residents and/or their representatives in writing of the reason for hospital transfers for three residents. The Director of Social Work admitted that the receptionist was responsible for sending notifications but failed to do so. The facility's policy was unclear about who should receive the email notice, leading to a lack of proper communication.
The facility failed to electronically transmit the MDS within 14 days of completing a resident's assessment. The discharge MDS for a resident, completed on 12/27/2023, was not transmitted until 03/18/2024, well beyond the required timeframe. The MDS Coordinator acknowledged the oversight, which was contrary to facility policy and CMS guidelines.
The facility failed to conduct a new PASRR level 1 assessment after a resident was newly diagnosed with bipolar disorder and psychotic disorder. The facility's policy did not require a new PASRR upon a new psychological diagnosis after admission, leading to the deficiency.
The facility failed to obtain physician orders for a resident's discharge, follow medication administration orders, and provide an air mattress for a resident at risk for pressure ulcers. A resident was discharged without a physician's order, another received incorrect medication administration, and a third was not provided with the ordered air mattress despite having a pressure ulcer.
The facility failed to accurately label multidose medications and left a multi-dose insulin vial unsecured on top of a medication cart. An LPN confirmed that medications should be dated upon opening, and the DON confirmed that medications should not be left unsecured, as per facility policies.
The facility failed to maintain a sanitary garbage container area, as observed by the surveyor during multiple visits. The Food Service Director and Director of Housekeeping acknowledged the issue, and the facility's policy required the area to be kept clean and free of debris.
The facility failed to implement appropriate transmission-based precautions for a resident with unspecified diarrhea and awaiting clostridium difficile test results. Additionally, two nurses were observed performing inadequate hand hygiene during medication administration, washing their hands for significantly less than the required twenty seconds.
Failure to Implement Resident Care Plan Intervention
Penalty
Summary
A deficiency was identified when a resident with a history of bipolar disorder, dementia, and anxiety disorder was observed on multiple occasions without a properly implemented intervention as outlined in their care plan. The resident's care plan included the use of a mesh stop sign across the door to prevent other residents from wandering into the room, an intervention initiated due to the resident's physical and verbal behaviors directed towards others as documented in the Minimum Data Set (MDS). However, during facility tours, the surveyor observed that the stop sign was not connected to both sides of the door as required. Interviews with facility staff confirmed that the care plan specified the use of the stop sign and that it was not being followed when the stop sign was not in place. The Unit Manager LPN acknowledged that the care plan was not being adhered to in these instances, and the DON affirmed that staff are expected to follow residents' care plans. The facility's policy also requires the interdisciplinary team to develop and maintain care plans in coordination with the resident and their family.
Failure to Administer Medications Within Required Time Frame
Penalty
Summary
The facility failed to follow prescriber's orders and accepted professional standards by administering medications outside the required time frame for two residents. One resident, admitted with diagnoses including a left humerus fracture, congestive heart failure, and depression, had a physician's order for Oxycodone 5 mg to be administered nightly at 9 PM. Medical records and audit reports showed that the medication was given late on multiple occasions, specifically being administered more than one hour after the prescribed time on several dates in January. Interviews with nursing staff confirmed that medications should be administered within one hour before or after the scheduled time, and administration outside this window is considered late. Another resident, with diagnoses including psoriatic arthritis and a pain management regimen of Oxycontin ER 20 mg every 12 hours, also received medications outside the required time frame. Audit reports indicated that the medication was administered late on numerous occasions, with delays ranging from over an hour to nearly three hours past the scheduled time. Facility policy requires medications to be administered within one hour of the prescribed time, and the observed practice did not comply with this standard.
Improper Food Labeling and Sanitation Practices Identified
Penalty
Summary
The deficiency identified during the survey involved the facility's failure to properly handle potentially hazardous foods and maintain sanitation to prevent foodborne illness. During the observation, the surveyor noted items in the walk-in freezer, including a spinach quiche, two packages of pulled pork, and a pie, lacking proper labeling and dates. The Food Service Director acknowledged the absence of required use-by labels for these items, contrary to the facility's policy on labeling and dating food items.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for resident rooms across three nursing units. Observations included partially removed vinyl wall coverings, broken wall bumpers with pointed edges, stained bathtubs, and damaged walls with exposed drywall. Additionally, some rooms had missing door knobs, exposed wires, and broken call bell control panels. The Director of Maintenance acknowledged the need for repairs when presented with photos of these issues. Further observations revealed additional deficiencies such as missing trash bags in garbage cans, stained privacy curtains, and broken furniture. Specifically, a dresser drawer was detached and leaning against the side of the dresser, and the floor baseboard was missing, exposing unfinished drywall. The Director of Maintenance confirmed that it was the maintenance department's responsibility to fix these issues but was unaware of the broken dresser and missing floor baseboard until the surveyor's observations. Another resident reported that seven floor tiles were missing in front of the sink, making it difficult to maneuver a wheelchair. Despite multiple observations by the surveyor, the tiles remained missing. The Director of Maintenance stated that staff should report such issues through the TELS system, but there was no record of this problem being reported. The facility's maintenance policy requires maintaining the building in good repair and free from hazards, which was not adhered to in these instances.
Failure to Ensure RN Coverage
Penalty
Summary
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. This deficiency was evidenced by the absence of RN coverage for all shifts on specific dates: 07/16/2022, 01/08/2023, 01/14/2023, 03/10/2024, and 03/16/2024. Additionally, there was no RN coverage on 07/17/2022, and although the Director of Nursing was present on 03/17/2024, the resident census was 136. During an interview, the Director of Nursing acknowledged that RNs are sometimes unavailable due to various reasons. The facility's policy on staffing states that adequate staffing, including licensed registered nursing staff, should be maintained to meet residents' needs and services.
Failure to Ensure Accountability of Narcotic Shift Count Logs
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs in accordance with its policy. This deficiency was identified on two of four medication carts reviewed during the Medication Storage Task. Specifically, the 1 East Low side cart and the 2 [NAME] High side cart had multiple instances where the narcotic shift count logs were incomplete. On several occasions, sections for positive, negative, and end shift totals were left blank, and signatures from both incoming and outgoing nurses were missing. Interviews with multiple LPNs confirmed that the logs should be completed by two nurses together at the end of each shift, but this procedure was not consistently followed. The Director of Nursing (DON) also confirmed that the controlled substance shift-to-shift logs are meant to be completed by two nurses to ensure accountability. A review of the facility's policy on controlled substances corroborated this requirement, stating that any discrepancies should be reported to the DON. Despite this policy, the surveyor found numerous instances of incomplete documentation, indicating a systemic issue with the facility's narcotic count procedures.
Failure to Ensure Monthly Consultant Pharmacist Visits
Penalty
Summary
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 deficiency was identified for three residents. For Resident #63, the CP reviewed medications monthly from January 2023 through October 2023, but there was no documentation for the subsequent three months. The resident had severe cognitive impairment and multiple medical diagnoses, including hypertension and anxiety disorder. The Director of Nursing (DON) confirmed that the CP had stopped coming and that the facility was in the process of securing a new CP, but no documentation was provided to support this claim. Similarly, Resident #83's medications were reviewed monthly from April 2023 through October 2023, with no documentation for the following three months. This resident had intact cognition and medical diagnoses including a history of deep vein thrombosis and quadriplegia. Resident #27 also had no CP review documentation for the same three months, despite having multiple medical conditions such as hypertension, bipolar disorder, and diabetes. The DON stated that during the absence of the CP, the facility conducted medication passes with nurses and reviewed new admissions' medications. The facility's policy required the CP to provide monthly drug regimen review reports, which was not adhered to during the specified period.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the reason for transfer or discharge to the hospital for three residents. Resident #129, who had severe cognitive impairment, was transferred to the hospital for right shoulder pain without written notification to the resident or their representative. The Director of Social Work (DSW) admitted that the receptionist was responsible for sending notifications but failed to do so. The policy for preparing a resident for transfer or discharge did not specify who should receive the email notice, leading to a lack of proper communication. Resident #43, with intact cognition, was transferred to the hospital twice, once for severe sepsis shock and another time for hypotension, without written notification to the resident or their representative. Similarly, Resident #230, who had intact cognition, was transferred to the hospital for ileostomy dysfunction without proper written notification. The DSW confirmed that the receptionist was supposed to send notifications to both the resident representative and the ombudsman but failed to do so. The facility's policy was unclear about who should receive the email notice, contributing to the deficiency.
Failure to Transmit MDS Within Required Timeframe
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) within 14 days of completing the resident's assessment. This deficiency was identified for one unsampled resident, who was discharged on an unspecified date. The discharge MDS for this resident was completed on 12/27/2023 but was not transmitted until 03/18/2024, well beyond the required timeframe. The MDS Coordinator acknowledged that the discharge MDS should have been completed within 14 days of discharge and transmitted within one week after completion, but it was missed. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual both stipulate that the discharge MDS must be completed and transmitted within specific timeframes, which were not adhered to in this case.
Failure to Update PASRR After New Mental Health Diagnosis
Penalty
Summary
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 deficiency was identified for a resident who had a PASRR level 1 completed previously, which was negative for any mental illness diagnoses. However, subsequent assessments, including the Quarterly Minimum Data Set (MDS), indicated the resident had been diagnosed with bipolar disorder and psychotic disorder. Despite these new diagnoses, no updated PASRR was conducted to reflect the changes in the resident's mental health status. Interviews with the Director of Social Service (DSS) and the Director of Nursing revealed that the facility's policy did not require a new PASRR upon a new psychological diagnosis after admission. The DSS confirmed that the PASRR was not redone with the new diagnosis, and the facility's policy did not address this scenario. The deficiency was identified during a survey, and it was noted that the facility's policy did not comply with the requirement to update PASRR assessments when new mental health diagnoses are made.
Failure to Follow Physician Orders and Provide Required Equipment
Penalty
Summary
The facility failed to obtain physician orders for a resident's discharge home, follow physicians' orders during medication administration, and provide an air mattress for a resident at risk for pressure ulcers. Resident #128 was discharged without a physician's order, despite the facility's policy requiring such an order. The Director of Nursing confirmed that a discharge order is necessary, and the facility's policy did not include obtaining a physician order as part of the discharge process. The resident was discharged with medications and instructions but without the required physician's order, indicating a lapse in following proper discharge procedures. During medication administration observations, RN #1 administered artificial tears to Resident #61 in both eyes, contrary to the physician's order, which specified administration in the right eye only. The RN acknowledged the error upon review of the physician's order. The resident's care plan and Medication Administration Record indicated the correct administration procedure, but the RN did not follow the physician's order, leading to improper medication administration. Resident #96, who had a diagnosis of a pressure ulcer, was observed lying on a standard mattress instead of the ordered air mattress. Despite the physician's order and care plan specifying the need for an air mattress, the resident was not provided with one. The nursing staff signed off on the Treatment Administration Record indicating that the air mattress was in place and functioning, but observations confirmed that the resident was on a standard mattress. The RN and LPN/Unit Manager acknowledged the oversight, and the Assistant Director of Nursing arranged for the correct mattress to be provided after the surveyor's observation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to accurately label multidose medications, which was observed during a survey of a medication cart. Specifically, an opened artificial tear bottle, a Spiriva inhaler, three Lantaprost ophthalmic solution eye drops, and a Dorzolamide hydrochloride and Timolol maleate ophthalmic solution eye drop bottle were found without dates indicating when they were opened. The Licensed Practical Nurse (LPN) confirmed that these medications should have been dated and initialed upon opening. The Director of Nursing (DON) also confirmed that opened medications should be dated, as per the facility's policy on labeling medication containers. Additionally, during a medication administration for a resident, an LPN left a multi-dose insulin vial unsecured on top of a locked medication cart in the hallway while administering an insulin injection. The LPN acknowledged that the insulin vial should have been placed in the drawer to prevent unauthorized access. The DON confirmed that medication should not be left unsecured on top of the cart, as per the facility's policy on administering medications.
Failure to Maintain Sanitary Garbage Container Area
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public by not maintaining the garbage container area free of garbage and debris. During an initial kitchen tour with the Food Service Director (FSD), the surveyor observed debris and trash around the dumpster area. The FSD mentioned that housekeeping was responsible for this area and speculated that no one had attended to it yet. Subsequent observations by the surveyor on different days noted continued debris and trash in the area behind the dumpster. An interview with the Director of Housekeeping revealed that housekeeping, maintenance, and the kitchen were all responsible for the parking lot, and he acknowledged that their responsibilities should extend beyond just the parking lot. The facility's policy on sanitation, dated November 15, 2022, stated that the dumpster and its surrounding area should be kept clean and free of debris, and any trash on the ground should be picked up and disposed of properly.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident diagnosed with unspecified diarrhea and awaiting test results for clostridium difficile. The resident's room did not have a transmission-based precaution sign, nor was there any personal protective equipment (PPE) available outside the room. Multiple staff members, including CNAs and an LPN, were observed entering and exiting the resident's room without wearing gowns. Interviews with staff confirmed a lack of awareness and adherence to the necessary precautions for a potentially infectious resident awaiting test results. Additionally, the facility failed to ensure effective hand hygiene practices among its nursing staff. During medication administration observations, two nurses were observed washing their hands for significantly less than the required twenty seconds. One nurse washed her hands for approximately three seconds, while another washed for fourteen seconds. Both nurses acknowledged the correct handwashing duration but did not adhere to it during the observed instances. The Director of Nursing confirmed that the handwashing times observed were insufficient and did not meet the facility's hand hygiene policy. These deficiencies highlight a lack of adherence to infection control protocols, specifically in the areas of transmission-based precautions and hand hygiene. The failure to implement these measures appropriately increases the risk of spreading infections within the facility, particularly for residents with potentially infectious conditions like clostridium difficile.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Whiting
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pines Village Inc | 1.6 mi | — | 0 | 0 |
| Crestwood Manor | 1.6 mi | — | 7 | 0 |
| Whiting Gardens Rehabilitation And Nursing Center | 2.6 mi | — | 9 | 1 |
| Complete Care At Arbors | 5.5 mi | — | 0 | 0 |
| Complete Care At Holiday City | 5.9 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.