Whiting Gardens Rehabilitation And Nursing Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
fracture (left upper arm). A review of the FRE conclusion provided by the facility indicated that CNA#1 did not properly follow the resident's Plan of Care for transfer resulting in the increased risk for falls. CNA #1 accepted responsibility and was terminated from employment. On 11/6/25 at 12:15 PM, the surveyor interviewed Resident #2 regarding the fall. The resident told the surveyor that the aide lined up the shower stretcher next to the bed and when the aide pulled the resident with the sheet the stretcher moved away and I fell on the floor, I knew my arm was broke. The resident said they were transferred immediately to the hospital. On 11/6/25 at 12:10 PM, the surveyor observed a CNA (CNA#2) pushing a mechanical lift down
the hallway. The surveyor asked about the procedure for use of the lift. CNA #2 said, You always need two people, if you don't have two people you don't use it until you do. On 11/6/25 at 12:25 PM, the surveyor interviewed a unit CNA (CNA#3) regarding assignments and resident needs. She told surveyor the assignment sheets have the resident's information and included if they were a one- or two-person assistance for transfer. The surveyor asked if they would ever have a problem getting a second person to help them for a two-person assistance resident and CNA#3 said never because the Unit Manager (UM) would always help. On 11/6/25 at 12:30 PM, the surveyor interviewed the unit Licensed Practical Nurse (LPN) regarding CNA assignments. She told the surveyor that before every shift the CNAs are handed an assignment sheet which included the resident assistance requirements for transfers. On 11/6/25 at 1:10 PM, the surveyor interviewed the UM of the South unit. The UM stated that the lead CNA or herself fill out
the CNA assignment sheets, and it includes transfer assistance requirements for residents. All mechanical lift residents are a two-person assistance. She told the surveyor that Resident #2 was a mechanical lift resident, and the CNA (CNA#1) should have had two people in the room with him. The UM told surveyor,
The CNA moved the resident with a sheet, and I don't know if the shower bed had the brakes on. The UM who was present on the unit, said the brakes were checked for function after the incident and they were in working order. On 11/6/25 at 1:45 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The surveyor asked the DON how a CNA would know if a resident was a one or two person transfer assist. The DON said besides assignment sheets
the CNAs have access to a Kardex in the Electronic Medical Record (EMR) which would include that information. The surveyor asked if CNA#1 should have had a second person with him and she said, Yes,
the resident was a mechanical lift transfer and help was available. He was educated that we don't attempt to maneuver unless they get help. He was agency and is no longer employed with us, and he accepted full responsibility. On 11/6/25 at 2:05 PM, the surveyor left a voice mail message for CNA #1 to return call.
Surveyor reviewed the policy titled, Daily Work Assignments with a revision date of August 2006. Under policy interpretation and implementations, Certified Nursing Assistants are expected to carry out their daily assignments in a profession manner and in accordance with established nursing procedures. A review of
the policy titled, Mechanical Lift (Hoyer) Transfers, an undated policy, the procedure was two staff were required. NJAC 8:39-27.1(a)
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WHITING GARDENS REHABILITATION AND NURSING CENTER in WHITING, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WHITING, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WHITING GARDENS REHABILITATION AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.