Inspection Reports for
King Manor Care And Rehabilitation Center
2303 West Bangs Ave, Neptune, NJ, 07753
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
73% occupied
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Deficiencies: 2
Date: Oct 27, 2025
Visit Reason
The inspection was conducted based on complaint #407581 to investigate allegations that the facility failed to notify a resident's physician and responsible party of a change in condition and failed to administer and document medication according to physician orders.
Complaint Details
Complaint #407581 was substantiated based on interviews, record reviews, and facility document reviews indicating failures in notification and medication administration/documentation for Resident #1.
Findings
The facility was found deficient for failing to notify the physician and responsible party of a resident's fever and for failing to administer and document acetaminophen medication as ordered. Documentation and monitoring of the resident's condition were also inadequate.
Deficiencies (2)
Failure to notify the resident's physician and responsible party of a change in condition (fever) for Resident #1.
Failure to administer and document acetaminophen medication according to physician order for Resident #1.
Report Facts
Resident reviewed: 1
BIMS score: 3
Medication dosage: 650
Temperature recorded: 100.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Interviewed regarding fever management and documentation practices | |
| Director of Nursing (DON) | Interviewed regarding staff responsibilities for fever management, documentation, and notification |
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
Complaint Investigation
Deficiencies: 6
Date: Oct 21, 2024
Visit Reason
The inspection was conducted based on complaint NJ 168449 regarding failure to provide appropriate and timely incontinence care and other quality of care concerns.
Complaint Details
Complaint NJ 168449 triggered the investigation due to allegations of inadequate incontinence care and other quality of care issues. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility was found deficient in providing timely and appropriate incontinence care to residents dependent on staff for ADLs, failure to follow physician orders for treatment of moisture-associated dermatitis, inadequate pressure ulcer care including turning and repositioning, lack of staff competency in dialysis access care, inconsistent hand hygiene practices, and malfunctioning call bell system in one resident room.
Deficiencies (6)
Failure to consistently provide appropriate and timely incontinence care for residents dependent on staff for ADLs.
Failure to follow physician order for treatment of moisture-associated dermatitis for Resident #3.
Failure to ensure a system was in place to turn and reposition a resident with pressure ulcers.
Failure to ensure staff were educated and competent in care of residents requiring hemodialysis and different types of access sites.
Failure to consistently perform hand hygiene to prevent spread of infection by licensed nurses and other staff.
Failure to ensure the call bell system was properly functioning in one resident's bathroom.
Report Facts
Residents reviewed for ADL care: 3
Residents reviewed for dialysis care: 2
Residents affected by deficiencies: 1
Residents affected by pressure ulcer care deficiency: 1
Rooms tested for call bell system: 5
Braden Scale score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Mentioned in relation to delayed incontinence care for Resident #3. | |
| Certified Nursing Assistant (CNA #2) | Provided incontinence care to Resident #3 and interviewed about care practices. | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding incontinence care and wound treatment for Resident #3. | |
| Director of Nursing (DON) | Interviewed regarding treatment orders and wound care for Resident #3 and pressure ulcer care. | |
| Assistant Administrator (AA) | Participated in pre-exit and exit conferences and acknowledged deficiencies. | |
| Rehabilitation Director (RD) | Provided information on pressure ulcer care and restorative programs. | |
| Registered Nurse (RN #1) | Interviewed about dialysis care and competency related to Permacath. | |
| Registered Nurse (RN #2) | Interviewed about dialysis care and competency related to AV fistula. | |
| Licensed Practical Nurse (LPN) | Observed during medication pass with hand hygiene deficiencies. | |
| Director of Activities (DA) | Observed with hand hygiene deficiencies during meal service. | |
| Certified Nursing Aide (CNA) | Observed with hand hygiene deficiencies during meal service. | |
| Director of Maintenance (DOM) | Tested call bell system functionality. | |
| Infection Preventionist | Interviewed about hand hygiene policies and practices. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 21, 2024
Visit Reason
The inspection was conducted based on complaint NJ 168449 regarding failure to provide appropriate and timely incontinence care for residents dependent on staff for Activities of Daily Living (ADLs).
Complaint Details
Complaint NJ 168449 was substantiated based on observations, interviews, and record reviews indicating failure to provide timely and appropriate incontinence care to residents dependent on staff for ADLs.
Findings
The facility failed to consistently provide timely and appropriate incontinence care to residents dependent on staff for ADLs, specifically Residents #3 and #184. Observations, interviews, and record reviews revealed delays in care, use of double incontinent briefs, and improper management of condom catheters, resulting in residents being soiled and at risk for skin breakdown.
Deficiencies (2)
Failure to provide timely incontinence care to Resident #3, including delayed response to call light and use of two saturated incontinent briefs.
Failure to provide timely incontinence care to Resident #184, including improper application and management of Condom Catheter leading to leakage and prolonged soiling.
Report Facts
Residents reviewed for ADL care: 3
Residents affected: 2
Brief Interview for Mental Status (BIMS) score: 15
Time delay for incontinence care: 24
Time staff availability: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Named in relation to delayed response and failure to check Resident #3 for incontinence care before breakfast. | |
| Certified Nursing Assistant (CNA #2) | Provided incontinence care to Resident #3 and reported use of two briefs without informing nurse. | |
| Licensed Practical Nurse (LPN) | Observed soiled brief on Resident #3 during survey. | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding incontinence care practices and unaware of double briefs usage. | |
| Certified Nursing Assistant (CNA) assisting Resident #184 | Confirmed failure to check Resident #184 prior to breakfast and assisted with incontinence care during survey. | |
| Assistant Administrator (AA) and Director of Nursing (DON) | Present during pre-exit conference where findings were presented. |
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 |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication management, environmental safety, and food service in the nursing home.
Findings
The facility was found deficient in maintaining a homelike environment accommodating resident needs, proper medication labeling and documentation, safe and sanitary kitchen equipment, and maintaining safe and sanitary resident room environments including hand sinks. Deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (4)
Failed to maintain a homelike environment that accommodated resident needs and preferences, specifically accessibility issues in Resident #59's room.
Failed to maintain medication carts free from unmarked and unwrapped medications and failed to accurately document administration of controlled medications.
Failed to maintain kitchen equipment in a manner to prevent microbial growth; spatulas and cutting boards were cracked, discolored, and pitted.
Failed to maintain a safe and sanitary environment in resident rooms; hand sinks and cabinets were in disrepair exposing particle board.
Report Facts
Residents reviewed: 22
Medication carts inspected: 2
Residents' rooms inspected for hand sinks: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Rehabilitation | Interviewed regarding room accessibility and environmental evaluations | |
| Certified Nursing Assistant (CNA) | Interviewed about bathroom door accessibility and resident mobility | |
| Licensed Practical Nurse (LPN) | Interviewed about medication administration and medication cart observations | |
| Unit Manager/Registered Nurse (UM/RN) | Interviewed about room accessibility and medication administration procedures | |
| Licensed Nursing Home Administrator (LNHA) | Confirmed expectations for room accessibility and medication administration | |
| Assistant Licensed Nursing Home Administrator (ALNHA) | Present during medication administration discussion | |
| Director of Nursing (DON) | Confirmed medication administration and inventory procedures | |
| Food Service Director (FSD) | Interviewed regarding kitchen equipment condition | |
| Maintenance Director (MD) | Interviewed about maintenance of sinks and cabinets |
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
Follow-Up
Deficiencies: 1
Date: Aug 9, 2021
Visit Reason
The visit was a follow-up inspection to verify correction of previously identified deficiencies related to food sanitation and safety practices in the facility's kitchen.
Findings
The facility failed to maintain proper sanitation to prevent food borne illness, evidenced by kitchen staff not properly wearing hair nets as required by facility policy and regulatory standards.
Deficiencies (1)
Food handlers did not wear hair nets that fully covered their hair, risking contamination of food.
Report Facts
Deficiency observation time: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Present during observation and interviewed regarding hair net policy enforcement | |
| Licensed Nursing Home Administrator | Interviewed regarding kitchen staff hair net requirements |
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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