Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Whiting Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident who was dependent on staff for transfers and required a mechanical lift with two-person assistance was transferred by a single CNA using a pull sheet, rather than the required equipment and staffing. During the transfer, the shower stretcher moved away, causing the resident to fall and sustain a left upper extremity fracture. The resident had multiple medical conditions and was fully dependent for transfers, with care plans and facility policies clearly indicating the need for two-person mechanical lift transfers. Staff interviews confirmed these requirements were standard practice.
A resident with dementia and behavioral issues was physically abused when an LPN used personal pepper spray on them during an episode of agitation, causing chemical conjunctivitis and pain. Surveillance footage showed the resident was left on the floor without medical assistance and later dragged back to their room by staff, with no care provided until emergency services arrived. Staff interviews confirmed the inappropriateness of the action, and facility policy at the time did not address weapons or pepper spray.
A cognitively impaired resident with a history of exit-seeking eloped from the facility due to inadequate supervision, lack of specific care plan interventions, and failure to follow protocols for monitoring and documentation. Staff did not notice the resident was missing until notified by an external caller, and post-incident checks of security systems were not performed. The required social services assessment was also not completed after the elopement.
The facility failed to perform quarterly smoking assessments for three residents who were active smokers, as required by their policy. One resident with moderate cognitive impairment had not been assessed for five months, another resident with intact cognition was overdue for an assessment by 63 days, and a third resident identified as an unsafe smoker had no further evaluations after the initial assessment. Conflicting information about responsibility for assessments indicated a lack of clarity within the facility.
The facility failed to ensure timely face-to-face visits by the attending physician for residents, as required by regulations. Several residents with serious conditions, such as dementia and bipolar disorder, were not seen by the physician within the mandated timeframes. Instead, APNs conducted visits and documented notes in the EMR, as confirmed by staff interviews.
The facility failed to maintain proper sanitation and food handling practices. A meat slicer was found uncovered with food debris, and pans were improperly air-dried, leading to wet nesting. In the pantry, a freezer had a thick ice buildup with debris, and staff were unaware of maintenance responsibilities.
The facility failed to maintain resident dignity during meal assistance, as staff were observed standing over residents while feeding them, contrary to the facility's policy requiring staff to sit at eye level. This was confirmed by the LNHA and DON, and observed on one unit where both an IP and a CNA did not adhere to the policy.
The facility failed to ensure residents were treated with dignity during meal assistance and did not create a homelike environment in the dining area. Staff were observed standing while assisting residents with meals, contrary to facility policy, and meals were served on trays, detracting from a homelike setting. The Licensed Nursing Home Administrator acknowledged these practices as inappropriate.
A resident with chronic kidney disease and hypotension did not receive Midodrine as prescribed when their systolic blood pressure (SBP) was below 100 mmHg, and received it when SBP was above 100 mmHg, contrary to physician's orders. The facility's Medication Pass policy lacked specific instructions for following hold parameters, leading to this deficiency.
A resident with a contracture in the right upper extremity was not provided with necessary assistive devices to maintain or improve range of motion. Despite recommendations for a handroll, the resident was observed without any such device, and the care plan lacked specific interventions for the contracture. Interviews with staff revealed inconsistencies in care and communication gaps regarding the resident's needs.
A resident with an indwelling urinary catheter was observed with the tubing dragging on the floor, contrary to infection control protocols. The resident, diagnosed with urinary tract infection and neuromuscular dysfunction of the bladder, had a care plan to keep the drainage bag off the floor, which was not followed. Staff interviews confirmed the tubing should not touch the ground, highlighting a deficiency in maintaining proper catheter care.
A facility failed to implement infection control measures for a resident with COPD by improperly storing a nebulizer mask. The mask was observed face down on personal belongings and undated, and later found exposed in a side table drawer. The resident had a history of COPD and was cognitively intact. The facility's policy did not address nebulizer care, and both the LPN and DON acknowledged the mask should have been bagged and labeled.
A facility failed to ensure consistent communication with a contracted dialysis facility for a resident requiring dialysis services. The resident, who had been receiving dialysis for five years, had missing entries for vital signs and other pertinent information on several dates. The LPN confirmed that the communication forms should be completed by the nursing staff before dialysis, but this was not consistently done. Interviews with the DON and LNHA revealed that the facility's process involved using a communication book, but the policy was not consistently followed.
A facility failed to maintain a Hospice Communication Record for a resident receiving hospice services. The resident, admitted with palliative care, depression, and sacral wounds, was identified as being on hospice care. The LPN/Unit Manager could not provide a complete Hospice Communication Book, only showing billing and symptom management documents. The facility's policy requires documented communication with hospice providers, which was not adequately maintained.
Multiple residents with cognitive and mental health conditions were subjected to physical and verbal abuse by another resident with a history of aggression and by an LPN. Despite recommendations for one-on-one supervision and behavior tracking, the facility did not consistently implement these interventions or revise care plans in response to ongoing aggressive behaviors and medication refusals. Staff-to-resident abuse was substantiated through witness statements and incident reports, with the LPN continuing to provide care after the first incident before being suspended and terminated.
Two residents with significant behavioral and medical diagnoses were involved in separate incidents where one was involuntarily secluded in a dayroom and another threw a knife and made threats toward staff and others. In both cases, the facility did not conduct or document thorough investigations as required by its abuse prevention policy, nor did it ensure the safety of all residents and staff involved.
The facility failed to prevent and address multiple incidents of physical and verbal abuse involving residents with behavioral health needs and staff, resulting in repeated aggression, injuries, and substantiated staff-to-resident abuse. Despite recommendations for one-on-one supervision and behavioral tracking, there was inconsistent implementation and documentation of these interventions, and staff were not always aware of required protocols. The facility did not consistently notify medical providers of medication refusals or behavioral incidents, and delays in reporting and investigating abuse were noted.
A resident with Huntington's disease and asthma, who was cognitively intact, was placed in a dayroom by a CNA, who then closed and blocked the door, preventing the resident from leaving despite repeated requests. The CNA sat outside the door to monitor the resident, and the incident was confirmed by interviews and surveillance footage. This action constituted involuntary seclusion and was not in accordance with facility policies on restraints and abuse prevention.
A resident with a history of TBI and dementia fell from a geriatric chair, sustained a forehead hematoma, and subsequently declined, exhibiting decreased alertness and inability to swallow. Facility staff did not complete or document required neurological assessments or monitor for delayed complications as per policy, and the incident was not properly recorded in the medical record or fall investigation documentation.
A resident with traumatic brain injury and severe dementia experienced multiple falls, including head injuries, due to inadequate supervision and ineffective interventions. Despite repeated incidents, the care plan was not consistently updated, root causes were not always documented, and increased monitoring was not implemented as required by facility policy. Staff interviews revealed that supervision was insufficient, particularly during mealtimes when one CNA was responsible for several high-fall-risk residents.
The facility did not complete or document required annual performance evaluations for all CNAs, with personnel files missing evaluations for one or more years. Staff interviews revealed confusion about who was responsible for conducting these reviews, and neither the ADON nor HR Director could locate the necessary documentation or policy.
The facility did not report allegations of abuse and threats in a timely manner to NJDOH as required by policy and regulation. In one case, a resident with dementia and a history of inappropriate behaviors was observed touching another resident inappropriately, but the incident was not reported to NJDOH within the required timeframe. In another case, a resident with schizophrenia and anxiety disorder displayed threatening behavior, and there was no evidence this was reported. Interviews confirmed that staff were aware of reporting requirements, but these were not consistently followed.
The facility did not ensure RN coverage for at least eight consecutive hours on a specific day, as confirmed by staffing records and staff interviews. This lapse was contrary to the facility's stated policy and regulatory requirements, potentially affecting all residents.
A resident with dementia and other conditions was involved in an altercation, leading to a room change. The facility failed to notify the resident's POA about the change and did not document the notification, violating resident rights. Interviews with staff confirmed the requirement for family notification and documentation, but the facility lacked a specific policy on room changes.
A resident with dementia, depression, and anxiety experienced a fall, but the LTC facility failed to update the care plan with new interventions as required. Despite being at risk for falls, the care plan had not been revised since January, and staff interviews confirmed the oversight. Facility policy mandates updates after significant changes, but this was not followed.
Failure to Follow Transfer Protocols Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for transfers was not safely or properly transferred according to their care plan. The resident, who required a mechanical lift and two staff members for transfers, was instead moved by a single CNA using a pull sheet from the bed to a shower stretcher. During this transfer, the shower stretcher moved away from the bed, causing the resident to fall to the floor and sustain a left upper extremity humeral fracture. The incident was witnessed after a nurse heard yelling and found the resident on the floor, with the CNA present in the room. The resident involved had multiple medical diagnoses, including heart disease, end stage renal disease, diabetes, and osteoporosis, and was assessed as being completely dependent on staff for transfers. The resident's care plan specifically required the use of a mechanical lift and two-person assistance for all transfers. Documentation in the facility's records, including the Minimum Data Set and assignment sheets, confirmed these requirements. Other staff interviews confirmed that the standard procedure for mechanical lift transfers was to have two staff members present, and that this information was clearly communicated to CNAs through assignment sheets and the electronic medical record. Despite these established protocols, the CNA involved in the incident did not follow the resident's care plan and attempted the transfer alone, without the mechanical lift or a second staff member. The facility's policies also required two staff for mechanical lift transfers. The failure to adhere to these procedures directly resulted in the resident's fall and injury.
Resident Abused with Pepper Spray by LPN; Left Without Care
Penalty
Summary
A moderately cognitively impaired resident with a history of dementia, severe mood disturbances, and major depressive disorder was subjected to physical abuse by a staff member. The resident, who had a care plan addressing aggressive and combative behaviors, was observed at the nurse's station exhibiting agitation, including grabbing and throwing equipment. In response, an LPN retrieved pepper spray from her personal belongings and sprayed the resident in the face multiple times, resulting in the resident collapsing to the floor, holding their eyes, and appearing to be in pain and distress. The resident was later treated for chemical conjunctivitis and pain to the left eye at the emergency room. Surveillance footage reviewed by facility leadership and law enforcement showed that after being sprayed, the resident was left on the floor without medical assistance as staff walked away. The resident attempted to crawl to an adjacent room while disoriented, at which point a CNA and the LPN dragged the resident by their clothing back to their room and left, again without providing care. No one else entered the resident's room until police and emergency medical services arrived. Interviews with staff confirmed that the use of pepper spray was not appropriate and that staff had been educated on abuse and the prohibition of such actions after the incident. Facility policy at the time prohibited physical abuse and required that law enforcement be called if a resident became violent or uncontrollable, but there was no explicit policy regarding weapons or pepper spray. The actions and inactions of the staff directly resulted in harm to the resident and constituted a failure to protect the resident from abuse and neglect.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A severely cognitively impaired resident with a history of exit-seeking behavior eloped from the facility. The resident, diagnosed with unspecified dementia, schizophrenia, and schizoaffective disorder, was independent with ambulation and had a BIMS score indicating severe cognitive impairment. The resident's care plan included interventions such as a wander guard, frequent monitoring of whereabouts, and documentation of wandering behavior, but there was no evidence of specific interventions to monitor the resident's whereabouts or to distract from wandering or exit-seeking behaviors. On the day of the incident, staff did not notice the resident was missing until notified by an external caller, and the resident was later returned by police without injury. Following the elopement, it was found that the facility did not test the wander guard system or egress doors immediately after the incident. The Director of Maintenance was not asked to check the doors or wander guard system post-incident, and only continued with routine weekly checks. Staff interviews revealed that no alarms were heard at the time of the elopement, and camera footage did not capture the resident exiting the facility. The Director of Nursing and Assistant Director of Nursing did not conduct a thorough root-cause analysis, as they did not interview all relevant staff or test the security systems after the event. Documentation of frequent monitoring and behavior logs, as required by the care plan, was not found in the resident's medical record. Additionally, the facility's elopement drill protocol required a social services assessment for emotional distress after an elopement, but this was not completed or documented for the resident. Staff were unclear about the meaning and documentation of "frequent monitoring," and there was no formal process or set time for such monitoring. The lack of specific interventions, inadequate supervision, failure to follow protocols, and insufficient documentation contributed to the resident's ability to elope undetected, resulting in a deficiency that placed the resident and others at risk.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to consistently perform quarterly smoking assessments for residents designated as active smokers, as required by their policy. This deficiency was observed in three residents. Resident #30, who has moderate cognitive impairment and multiple diagnoses including Parkinson's disease and dementia, had not received a quarterly smoking assessment since August 2024, despite being an active smoker. The resident's care plan did not address the need for quarterly smoking assessments, and the last assessment was overdue by approximately five months. Resident #127, who has intact cognition and diagnoses including traumatic subdural hemorrhage and seizures, was observed smoking without staff supervision. The resident's smoking safety evaluation was overdue by 63 days, with the last assessment due in November 2024. The facility's corporate activity director and nursing staff provided conflicting information about who was responsible for completing smoking assessments, indicating a lack of clarity and communication within the facility. Resident #58, who is cognitively intact and has multiple diagnoses including metabolic encephalopathy and major depressive disorder, was identified as an unsafe smoker. However, no further smoking evaluations were conducted after the initial assessment in August 2024. The facility's smoking policy requires quarterly re-evaluations of a resident's ability to smoke safely, but this was not adhered to, contributing to the deficiency.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at the required intervals. Specifically, the attending physician did not see residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This deficiency was identified for 8 out of 35 sampled residents, including those with serious conditions such as dementia, bipolar disorder, and chronic obstructive pulmonary disease. For instance, Resident #139, admitted with dementia and anxiety disorder, was not seen by the attending physician from June 2024 to January 2025. Similarly, Resident #79, with bipolar disorder and neuropathy, had no documented visits by the attending physician since July 2024. Other residents, such as Resident #59 with bipolar disorder and non-Alzheimer's dementia, and Resident #120 with cauda equina syndrome and obstructive uropathy, also lacked timely physician visits. Interviews with facility staff, including LPNs and the Medical Director, revealed that the facility relied on Advanced Practice Nurses (APNs) to conduct visits and document notes in the Electronic Medical Record (EMR). The Medical Director confirmed that they typically see patients in the hospital and do not write physician notes, leaving this task to the APNs. The facility's policy, revised in April 2013, mandates compliance with OBRA regulations, which were not adhered to in this case.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. During an inspection, a meat slicer was found uncovered and exposed to air, with unidentified food debris and a white slimy substance present on the table behind the blade guard. The Food Service Director (FSD) confirmed that the slicer was cleaned and sanitized, but it was not covered when not in use, exposing it to potential contamination. Additionally, a stack of deep 1/4 pans was observed to be wet, indicating improper air drying before stacking, a practice known as wet nesting, which can promote bacterial growth. In the North Pantry/Nourishment room, a thick buildup of ice was observed at the bottom of the freezer, containing a white plastic spoon, pieces of napkin, aluminum foil, and Styrofoam. Bagged ice packs were stored alongside resident food, and the Licensed Practical Nurse/Unit Manager (LPN/UM) was unaware of who was responsible for the freezer's maintenance. The facility's policy on sanitization and cleanliness was reviewed, highlighting the need for proper air drying of equipment and utensils to prevent cross-contamination.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity while being assisted with meals. This deficiency was observed on one of the facility's units, where staff members were seen standing over residents while feeding them, rather than sitting at eye level as required by the facility's feeding assistance guidance. On one occasion, the Infection Preventionist was observed standing over a resident seated in a Geri chair while assisting with a meal, and admitted to the surveyor that they did not have a chair to sit on. On another occasion, a Certified Nursing Assistant (CNA) was observed standing while assisting two different residents with their meals, despite a chair being available for use. The Licensed Nursing Home Administrator and Director of Nursing confirmed during an interview that staff are supposed to sit while assisting residents with meals, aligning with the facility's policy. The facility's policy, titled 'Feeding Assistance Guidance,' explicitly states that staff should sit facing the resident at eye level. This practice was not followed, leading to the deficiency being cited under NJAC8:39-4.1(a)(12).
Deficiency in Dignity and Homelike Environment During Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal assistance and did not create a homelike environment in the dining area. On multiple occasions, staff members, including the Infection Preventionist and a Certified Nursing Assistant, were observed standing while assisting residents with their meals, rather than sitting at eye level as per facility policy. This practice was noted in both the [NAME] wing and South wing, affecting residents seated in Geri chairs. Despite the availability of chairs, staff continued to stand, which was acknowledged as inappropriate by the Licensed Nursing Home Administrator during an interview. Additionally, the facility did not remove food from trays when serving meals in the dining room, which detracted from creating a homelike environment. This was observed on several occasions in the South Unit dining room, where residents were served their meals directly on trays. The Licensed Nursing Home Administrator admitted that serving meals on trays was a longstanding practice, despite it not aligning with the goal of providing a homelike dining experience. The facility's policy on feeding assistance, which advises staff to sit facing residents at eye level, was not adhered to, contributing to the deficiency.
Failure to Follow Medication Hold Parameters for Blood Pressure Management
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following the hold parameters for administering a blood pressure medication, Midodrine, to a resident with chronic kidney disease and hypotension. The resident, who was moderately cognitively impaired and dependent on renal dialysis, had a physician's order specifying that Midodrine should be administered when the systolic blood pressure (SBP) was less than 100 mmHg. However, the Medication Administration Records (MAR) for November and December 2024, and January 2025, revealed multiple instances where the resident's SBP was below 100 mmHg, yet Midodrine was not administered. Conversely, there were also instances where Midodrine was given when the SBP was above 100 mmHg, contrary to the physician's order. Interviews with the nursing staff, including an LPN and a Unit Manager, confirmed that the nurses did not follow the physician's hold order parameters for Midodrine on multiple occasions. The Director of Nursing acknowledged that the nurses should have adhered to the physician's orders. Additionally, the facility's Medication Pass policy did not include specific instructions for following physician's orders regarding medication hold parameters, contributing to the oversight in medication administration for the resident.
Failure to Provide Appropriate Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with a contracture, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, identified as having a contracture in the right upper extremity, was observed multiple times without any assistive devices such as a splint or handroll, which are typically used to prevent further decrease in ROM. Despite the resident's family being informed that an appropriate device would be provided, no such device was observed during the surveyor's visits. The resident's medical records indicated a history of cerebral infarction and major depression, with a moderately impaired cognitive status. The care plan for the resident included monitoring for signs of immobility and providing gentle ROM exercises, but it lacked specific interventions for the contracture of the right hand. Additionally, there were no active physician orders addressing the contracture, and previous therapy recommendations for wearing a handroll were not being followed. Interviews with facility staff revealed a lack of consistent application of assistive devices and a gap in communication regarding the resident's care needs. The head therapist confirmed that the resident had not been on therapy since early 2024, and the discharge recommendations for wearing a handroll were not implemented. The Director of Nursing outlined general interventions for residents with contractures, but these were not reflected in the resident's care plan or observed in practice.
Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with an indwelling urinary catheter. During an observation, the surveyor noted that the tubing of the urinary collection bag was dragging on the ground as the resident self-ambulated in a wheelchair. The resident, who had a diagnosis of urinary tract infection, dementia, and neuromuscular dysfunction of the bladder, was cognitively intact with a BIMS score of 14/15. The resident's care plan included interventions to keep the drainage bag off the floor and covered for dignity, but these were not followed. Interviews with facility staff, including the Infection Preventionist, LPNs, and the Director of Nursing, confirmed that the urinary collection tubing should never touch the ground due to infection control concerns. The facility's Foley Catheter Care policy stated that the drainage bag must not touch the floor, but it did not explicitly mention the tubing. The deficiency was identified as a failure to adhere to infection control protocols, as the tubing was observed on the floor, posing a risk of cross-contamination and infection.
Improper Storage of Respiratory Equipment for Resident with COPD
Penalty
Summary
The facility failed to implement proper infection control measures for the handling and storage of respiratory equipment for a resident with COPD. During an initial tour, a surveyor observed a nebulizer mask belonging to the resident placed face down inside the bedside on top of personal belongings, such as a book and a mirror, and the mask was undated. Subsequent observations revealed the nebulizer mask was consistently stored improperly, either inside a side table drawer or on top of the side table, exposed and undated. The resident, who was cognitively intact, had a history of COPD and was admitted with other diagnoses, including atrial fibrillation. The facility's documentation showed that the resident had a physician's order for Albuterol Sulfate Inhalation Nebulization Solution, which was discontinued in August 2024. Despite this, the nebulizer mask was not stored according to infection control protocols. The resident's care plan included interventions for COPD, such as the administration of bronchodilators as ordered. However, the facility's Oxygen Administration policy did not address the care or storage of nebulizers. Both the resident's LPN and the DON acknowledged that the nebulizer mask should have been bagged and labeled when not in use.
Failure to Ensure Consistent Communication with Dialysis Facility
Penalty
Summary
The facility failed to ensure consistent communication with a contracted dialysis facility for a resident requiring dialysis services. This deficiency was identified for a resident who had been receiving dialysis treatment for approximately five years due to end-stage renal disease and other related conditions. The resident attended dialysis four days a week, and the facility's policy required the use of a communication book to document vital signs and other pertinent information before the resident's departure for dialysis. Upon review, it was found that the facility did not consistently document necessary information on the dialysis communication forms. Specifically, there were missing entries for vital signs, access site status, and any problems or complaints on several dates. The Licensed Practical Nurse (LPN) responsible for the resident confirmed that the top portion of the communication form should be completed by the facility's nursing staff before the resident's dialysis treatment. However, this was not consistently done, leading to incomplete communication records. Interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) revealed that the facility's process involved using a communication book for documenting and communicating with the dialysis center. The DON acknowledged that the nursing staff was responsible for ensuring the completion of the communication forms before the resident's departure for dialysis. Despite this, the facility's policy was not consistently followed, resulting in incomplete documentation and communication with the dialysis center.
Failure to Maintain Hospice Communication Record
Penalty
Summary
The facility failed to maintain a Hospice Communication Record for a resident receiving hospice services. During an initial tour, the surveyor observed the resident in their room and identified them as receiving hospice care. The resident was admitted with diagnoses including palliative care, depression, and sacral wounds. The most recent Minimum Data Set indicated the resident was on hospice care, and their comprehensive care plan included coordination with hospice and notification of any changes in condition or medication. During an interview, the LPN/Unit Manager was unable to provide a complete Hospice Communication Book for the resident, only presenting two documents related to billing and symptom management. The facility's hospice program policy requires communication with the hospice provider to ensure resident needs are met 24/7, but the documentation was insufficient. This lack of documentation and communication with hospice providers led to the identified deficiency.
Failure to Protect Residents from Abuse by Peer and Staff
Penalty
Summary
The facility failed to protect multiple residents from physical and verbal abuse by both another resident and a staff member. One resident with a history of mental illness, aggressive behavior, and non-compliance with psychotropic medication physically assaulted two other residents on separate occasions. Despite documented recommendations for one-on-one supervision and behavior tracking, there was no evidence that these interventions were consistently implemented or that the care plan was revised in response to ongoing aggressive behaviors and repeated medication refusals. The facility did not provide documentation that the physician was notified or that behavior tracking was forwarded as recommended, and staff interviews revealed a lack of awareness regarding supervision requirements. Additionally, two residents were subjected to physical and verbal abuse by an LPN on two separate occasions. Witness statements and incident reports confirmed that the LPN pushed one resident and yelled at them, and on another occasion, used expletives and physically struck another resident's hand while attempting to take a binder away. The incidents were witnessed by other staff, and the LPN continued to provide care after the first incident before being suspended and subsequently terminated following the second incident. The facility's own investigation substantiated the staff-to-resident abuse. The residents involved had varying degrees of cognitive impairment and medical conditions, including dementia, anxiety disorder, depression, and chronic illnesses. The facility's failure to implement and maintain appropriate interventions, revise care plans, and ensure staff adherence to abuse prevention policies resulted in actual harm to the residents and placed them in situations of immediate jeopardy.
Removal Plan
- Educate the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on investigating allegations of abuse
- Review and revise policies
- Educate staff on abuse
Failure to Investigate Abuse Allegations and Threats
Penalty
Summary
The facility failed to ensure residents' safety by not conducting thorough and complete investigations into allegations of abuse and threats involving two residents. In one incident, a resident with Huntington's disease, muscle weakness, gait instability, and anxiety disorder, who was cognitively intact, reported being placed in a dayroom against their wishes during the night shift. The resident stated that a CNA, following a nurse's instructions, placed them in the dayroom with the door closed and sat outside the door, preventing the resident from leaving. The resident expressed fear and distress during the incident, and the facility's documentation confirmed that the resident was kept in the room against their wishes. However, the facility could not provide evidence of a comprehensive investigation, including interviews with all involved staff and assessment of resident safety. In a separate incident, another resident with schizophrenia and anxiety disorder was observed by an LPN throwing a knife into the hallway and making ongoing verbal and physical threats toward staff and other residents. Despite the seriousness of the behavior, the facility was unable to provide documentation that a thorough investigation was conducted to ensure the safety of other residents and staff. There was no evidence that the incident was fully investigated or that appropriate steps were taken to assess the situation and prevent further harm. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention requires protection of residents from abuse and the maintenance of a culture of compassion and caring, particularly for those with behavioral or emotional problems. In both incidents, the facility failed to implement its own policy and procedures, as there was a lack of documented evidence of complete investigations and follow-up actions to ensure resident safety following the reported events.
Failure to Prevent and Address Resident and Staff Abuse
Penalty
Summary
The facility failed to ensure the safety and well-being of residents by not adequately preventing or addressing incidents of physical and verbal abuse, as well as not following its own policies regarding abuse prevention, physical restraints, and behavioral management. Multiple residents with cognitive and behavioral health diagnoses, including schizophrenia and dementia, were involved in repeated altercations and aggressive incidents. One resident with schizophrenia exhibited ongoing aggressive and violent behaviors towards both staff and other residents, including physical assaults, threats, and property damage. Despite recommendations from psychiatric consultants and outreach programs for one-on-one supervision and behavioral tracking, there was no consistent documentation that these interventions were implemented or that the physician was notified of ongoing medication refusals. The resident continued to refuse medications and engaged in multiple aggressive episodes, some resulting in injuries to other residents and staff, without evidence of timely or adequate intervention by facility leadership. In addition to resident-to-resident aggression, the report documents substantiated incidents of staff-to-resident abuse. An LPN was witnessed pushing and yelling at a resident and using inappropriate language and physical force with another resident. These incidents were observed by other staff members, and the involved LPN continued to provide care after the initial incident before being suspended and ultimately terminated. The facility's documentation revealed delays in reporting and investigating these abuse allegations, and there was a lack of immediate protective measures for the affected residents. Interviews with staff indicated that some were unaware of required supervision protocols, and there was confusion regarding the implementation and discontinuation of one-on-one supervision for residents with behavioral issues. The facility did not provide evidence that all recommended safety measures, such as consistent one-on-one supervision, behavioral tracking, and timely notification of psychiatric and medical providers, were followed. There was also a lack of documentation regarding the rationale for discontinuing supervision and the communication of behavioral incidents to appropriate authorities. The failure to implement and document these interventions contributed to repeated episodes of aggression, injury, and abuse among residents and staff, in violation of facility policies and regulatory requirements.
Involuntary Seclusion of Resident in Dayroom by CNA
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) placed a resident in the dayroom, closed and blocked the door, and sat outside to prevent the resident from leaving, despite the resident's repeated requests to exit. The resident reported feeling terrified and begged to be let out, but the CNA did not allow it. The incident was corroborated by interviews, surveillance footage, and statements from both the resident and staff, which confirmed that the resident was kept in the dayroom against their wishes. The resident involved had a diagnosis of Huntington's disease and asthma, and was assessed as having intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. The event occurred during the night shift, when the resident was found in the hallway and redirected to the dayroom by the CNA, following instructions from a nurse to keep the door closed due to fall risk concerns. The CNA remained outside the door, monitoring the resident and others in the dayroom, but did not permit the resident to leave when requested. Facility documentation, including the Reportable Event Record and investigative summaries, confirmed that the resident was involuntarily secluded in the dayroom. The facility's own policies on physical restraints and abuse prevention were not followed, as these policies prohibit involuntary seclusion and require the protection of residents' rights to freedom from such practices. The incident was reported, and the CNA involved was suspended following the event.
Failure to Assess and Monitor Resident After Fall Resulting in Hematoma
Penalty
Summary
The facility failed to assess and monitor for delayed complications after a resident fell from a geriatric chair in the day room and sustained a hematoma. The facility did not follow its own policy, which required observation for delayed complications for approximately 48 hours after a fall and documentation of findings in the medical record. There was no evidence in the resident's electronic medical record that a neurological assessment was completed or that the facility's fall assessment policy was implemented after the incident. The nursing progress notes lacked documentation of the resident's status following the fall, and the fall investigation packet did not include a neurological assessment. The resident involved had a history of traumatic brain injury, unspecified dementia with behavioral disturbances, and was severely impaired in decision making. After the fall, the resident exhibited a decline, including inability to swallow, drooling, decreased alertness, and bruising on the forehead, as observed by family members and staff. Interviews with staff and the medical director confirmed that the required assessments and monitoring were not documented or performed according to policy, and the director of nursing acknowledged the expectation for neurological assessments and documentation following such incidents.
Failure to Provide Adequate Supervision and Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent repeated falls for a resident with a history of traumatic brain injury and severe dementia. The resident was dependent on staff for all activities of daily living and exhibited behavioral symptoms, including attempts to get out of bed, wheelchair, and geriatric chair. Despite multiple falls, including incidents where the resident sustained head injuries and required emergency treatment, the facility did not consistently document the root causes of the falls or update the care plan with new interventions after each event. Review of the facility's fall management policy indicated that staff were required to identify and implement interventions based on the resident's specific risks and to re-evaluate and modify interventions if falls recurred. However, after several falls, the care plan was not promptly updated with new or different interventions, and there was no evidence that increased monitoring was implemented as documented. Staff interviews revealed that supervision in the day room was insufficient, especially during mealtimes when one CNA was responsible for feeding and monitoring multiple high-fall-risk residents. Interviews with nursing staff and management confirmed that falls were discussed in meetings, but the interdisciplinary team did not consistently meet after each fall to re-evaluate interventions. The staff acknowledged that the interventions in place were not effective in preventing further falls for the resident, and there was a delay in increasing supervision or changing the approach despite repeated incidents.
Failure to Complete and Document Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct and document annual performance evaluations for all Certified Nursing Assistants (CNAs) as required. Review of personnel files for five CNAs revealed missing or outdated Performance Evaluations for Non-Exempt Employees (PENEE), with some files lacking evaluations for one or more years. Interviews with CNAs confirmed that annual reviews had not been completed in the past year or more. Additionally, the facility was unable to provide documentation or evidence of completed evaluations for the required periods. Further interviews with facility staff, including the Unit Manager, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Human Resources (HR) Director, revealed confusion regarding responsibility for completing the annual evaluations. The Unit Manager admitted to not completing the reviews in recent years and was unsure who was responsible. The DON stated that direct managers were supposed to complete the reviews, coordinated through HR, but the ADON and HR Director could not locate the necessary documentation or a performance review policy. This lack of clarity and documentation led to the identified deficiency.
Failure to Timely Report Abuse Allegations and Threats
Penalty
Summary
The facility failed to report allegations of abuse in a timely manner to the New Jersey Department of Health (NJDOH) and did not follow its own policy on abuse, neglect, exploitation, and misappropriation prevention. Specifically, an incident occurred in which one resident with dementia and a history of sexually inappropriate behaviors was observed by a CNA touching another resident, also with dementia and severely impaired cognition, inappropriately while both were fully clothed. The incident was reported to the nurse immediately, but the facility did not notify NJDOH until more than two hours after the event, which was not in accordance with federal requirements or facility policy. Documentation showed the incident occurred at 8:30 p.m. and was reported to NJDOH at 12:30 p.m. the following day. Additionally, another resident with schizophrenia and anxiety disorder was reported by an LPN to have thrown a knife into the hallway and continued to display verbal and physical threats toward staff and other residents. The facility could not provide evidence that these verbal threats were reported to NJDOH as required. Interviews with the DON confirmed that all allegations of abuse, including resident-to-resident abuse and threats, should be reported to NJDOH within two hours, but this was not consistently done. The Administrator also indicated a misunderstanding of what incidents were reportable, further contributing to the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours on 08/29/23, as required by regulation. Review of the Nurse Staffing Report for that date showed no RN coverage for the required period. The Unit Secretary/Staffing Coordinator, responsible for scheduling, confirmed that RN coverage is typically arranged for eight hours daily but could not recall the reason for the lapse on the specified date. The Director of Nursing acknowledged the expectation for federal compliance. This deficiency had the potential to affect all 157 residents in the facility, as the absence of RN coverage was not in accordance with the facility's stated staffing policy and regulatory requirements.
Failure to Notify POA of Room Change
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) about a room change and did not document this notification in the progress notes, violating Mandatory Resident Rights. This deficiency was identified during a review of a resident who had been involved in a physical altercation with another resident, leading to a room change. The resident, who had a history of unspecified dementia, major depressive disorder, and hypertension, was assessed with a moderately impaired cognitive status. Despite the facility's protocol requiring family notification and documentation in such cases, there was no record of the POA being informed about the room change. Interviews with facility staff, including the Licensed Practical Nurse Unit Manager (LPN UM) and the Licensed Nursing Home Administrator (LNHA), confirmed that family notification should occur before a room change and be documented in the resident's progress notes. The Director of Nursing (DON) and LNHA emphasized the importance of this practice as a resident's right. However, the facility lacked a specific policy on room changes and notification, as revealed by the DON, who provided a document titled Subchapter 4: Mandatory Resident Rights, which outlines the resident's right to be notified of room changes.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement care plan interventions for a resident following a fall, as required by their policy. The resident, who was admitted with diagnoses including dementia, depression, and anxiety disorder, had a fall on September 8, 2024. Despite being identified as at risk for falls, the resident's care plan had not been updated with new interventions since January 29, 2024. This oversight was confirmed during interviews with the Licensed Practical Nurse Unit Manager (LPN UM) and the Director of Nursing (DON), who acknowledged that the care plan should have been updated within 24 to 48 hours after the incident. The facility's policy on comprehensive person-centered care plans mandates that care plans be revised when there is a significant change in a resident's condition, such as a fall. However, the care plan for the resident in question was not updated after the fall, and no new interventions were added. The DON confirmed that interventions are typically discussed during falls huddle meetings, but in this case, the care plan remained unchanged, contrary to the facility's policy and expectations.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 274 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 1.1 mi | — | 0 | 0 |
| Crestwood Manor | 1.1 mi | — | 7 | 0 |
| Aristacare At Whiting | 2.6 mi | — | 0 | 0 |
| Aristacare At Manchester | 5.4 mi | — | 0 | 0 |
| Complete Care At Arbors | 5.9 mi | — | 0 | 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.