Inspection Reports for King Manor Care And Rehabilitation Center
2303 West Bangs Ave, Neptune, NJ, 07753
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of deficiencies related primarily to resident care, infection control, and life safety code compliance. Complaint investigations from 2021 and 2024 included substantiated issues with activities of daily living care, pressure ulcer prevention, dialysis, infection control, and safety systems, while other complaints were found unsubstantiated. The facility faced an immediate jeopardy finding in early 2021 related to COVID-19 infection control, which was resolved promptly, and no fines or license actions were listed in the available reports. The inspection history suggests some improvement over time, with the most recent survey free of citations after prior mixed results.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
87 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: 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, the circumstances under which health information may be used or disclosed, the rights of individuals to access and control their information, and the legal duties of NJDHSS to protect privacy.
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 contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 7
Date: Oct 25, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by complaints #168449, 178432, 171700, and 178432.
Complaint Details
The visit was complaint-related with complaints #168449, 178432, 171700, and 178432. The survey findings substantiated deficiencies in care and safety.
Findings
Deficiencies were cited related to Activities of Daily Living (ADL) care, quality of care, treatment to prevent and heal pressure ulcers, dialysis, infection prevention and control, resident call system, and life safety code violations. The facility failed to provide consistent and timely care, follow physician orders, maintain proper infection control, and ensure safety measures such as fire alarm inspections and call bell functionality.
Deficiencies (7)
Failure to consistently provide appropriate and timely ADL care for dependent residents.
Failure to follow physician orders for treatment and care.
Failure to ensure skin integrity and prevent pressure ulcers.
Failure to provide adequate dialysis care and assessment.
Failure to maintain infection prevention and control practices, including hand hygiene.
Failure to maintain a functioning resident call system.
Failure to maintain life safety code compliance including fire alarm inspections, fire extinguisher availability, smoke barrier integrity, and elevator safety.
Report Facts
Sample size: 23
Residents reviewed: 21
Residents affected: 87
Deficiency corrections completion dates: Various deficiencies have correction completion dates ranging from 11/15/2024 to 12/13/2024.
Staffing ratios: 10
Certified Nurse Aides (CNAs) staffing: 7
Certified Nurse Aides (CNAs) staffing: 8
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 16
Date: Jun 15, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint NJ #: 153047; 155078; 161130
Findings
Deficiencies were cited related to reasonable accommodations for residents, medication labeling and storage, food safety, environmental conditions, staffing ratios, and life safety code compliance including fire safety, means of egress, fire alarm and sprinkler systems, and electrical safety.
Deficiencies (16)
Facility failed to maintain a homelike environment accommodating resident needs and preferences, evidenced by Resident #59's room accessibility issues.
Medication carts contained unmarked and unwrapped medications and inaccurate documentation of controlled medication administration.
Facility failed to maintain kitchen equipment to prevent microbial growth, including cracked spatulas and discolored cutting boards.
Facility failed to maintain safe and sanitary environment in residents' rooms due to damaged sink cabinets and missing molding exposing particle board.
Facility failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey.
Means of egress was obstructed by storage in a 58-foot long dead-end corridor.
One exit discharge door had a thumb turn lock restricting emergency egress; lock was replaced with a panic exit device.
Six of twelve exit discharge doors lacked continuous illumination or sufficient lighting fixtures.
One of two chute doors failed to self-close and positive latch to maintain 1.5-hour fire rated construction.
One of five fire-rated doors to hazardous areas was not self-closing and lacked smoke resisting partitions.
Facility failed to maintain fire alarm and detection system in optimum condition; one smoke detector had dust buildup obstructing sensing chamber.
Sprinkler system had multiple deficiencies including missing escutcheon cap, improper sprinkler head installation, missing ceiling tiles affecting sprinkler coverage.
Two portable fire extinguishers in maintenance area lacked evidence of monthly inspections for several months.
Smoke barrier partitions had unsealed penetrations allowing smoke, fumes, and fire to pass between compartments.
Two electrical outlets near water sources lacked ground-fault circuit interrupter (GFCI) protection.
Emergency generator lacked a remote manual stop station.
Report Facts
Sample size: 27
Length of dead-end corridor: 58
Width of dead-end corridor: 38
Room size: 206
Number of portable fire extinguishers inspected: 26
Number of smoke detectors: 116
Number of exit discharge doors: 14
Number of electrical outlets tested: 5
Staffing ratios: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to facility maintenance and safety issues | |
| Licensed Nursing Home Administrator | Named in multiple findings and exit conferences | |
| Director of Nursing | Named in medication cart and staffing findings | |
| Unit Manager/Registered Nurse | Interviewed regarding room accessibility and staffing | |
| Director of Rehabilitation | Interviewed regarding resident room accessibility | |
| Certified Nursing Assistant #1 | Interviewed regarding room accessibility | |
| Licensed Practical Nurse | Interviewed regarding medication cart and room accessibility | |
| Unit Manager/Registered Nurse | Interviewed regarding maintenance reporting |
Document
Deficiencies: 0
Date: Aug 9, 2021
Visit Reason
This document does not contain any inspection or regulatory information; it is an instructional cover page.
Findings
No findings or inspection content is present in this document.
Inspection Report
Life Safety
Deficiencies: 3
Date: Aug 9, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found non-compliant with several Life Safety Code requirements including emergency lighting backup, damaged and improperly positioned grease baffles in the kitchen exhaust hood system, and failure to certify that the emergency generator transfers power within the required 10-second timeframe.
Deficiencies (3)
Failed to provide a battery backup emergency light above the emergency generator's transfer switch independent of the building's electrical system.
Exhaust hood grease baffles were damaged and improperly positioned in 12 of 20 observed sections, compromising fire safety.
Failed to certify that the emergency generator transfers power to the building within the required 10-second timeframe as per NFPA 99.
Report Facts
Grease baffles damaged: 12
Load tests without transfer time data: 12
Generator load test dates: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews confirming deficiencies | |
| Administrator in training | Present during observations and interviews confirming deficiencies | |
| Dietary Director | Present during observations and interviews confirming grease baffle deficiencies |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ136218, NJ140583, NJ134024, and NJ136174.
Complaint Details
Complaint numbers NJ136218, NJ140583, NJ134024, and NJ136174 were investigated and found to be in compliance.
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.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Date: Mar 25, 2021
Visit Reason
The visit was conducted as a complaint investigation to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Complaint Details
The visit was complaint-related and the facility was found compliant; no deficiencies were cited.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Abbreviated Survey
Census: 74
Deficiencies: 1
Date: Feb 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 2/4/21 and 2/8/21 to assess compliance with infection control regulations related to COVID-19.
Findings
The facility failed to implement mitigation strategies including transmission-based precautions by not identifying residents exposed to COVID-19 as persons under investigation (PUI), posing a serious and immediate threat to non-ill residents. Immediate Jeopardy was identified on 2/4/21 and removed on 2/5/21 after the facility implemented a removal plan including isolation rooms, PPE availability, staff education, and cohorting.
Deficiencies (1)
Failure to identify residents exposed to COVID-19 as persons under investigation (PUI) and implement transmission-based precautions to prevent spread of COVID-19.
Report Facts
Census: 74
Sample size: 5
Date of Immediate Jeopardy notification: Feb 4, 2021
Date of Immediate Jeopardy removal: Feb 5, 2021
Number of residents at risk on affected unit: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided information about facility units, staff assignments, and infection control practices. | |
| Licensed Practical Nurse (LPN #1) | Tested positive for COVID-19 and was the source of exposure; worked on affected nursing unit. | |
| Licensed Nursing Home Administrator (LNHA) | Participated in entrance conference and provided information about staff and resident cohorts. | |
| Infection Preventionist/Unit Manager (IP/UM) | Assisted in entrance conference and infection control oversight. | |
| Licensed Practical Nurse (LPN #2) | Interviewed regarding isolation practices on the affected unit. | |
| Certified Nursing Assistant (CNA) | Interviewed regarding isolation practices and PPE use on the affected unit. |
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