King Manor Care and Rehabilitation Center

Complaint #: 407581Based on interviews, review of medical records, and pertinent facility documents, it was determined that the facility failed to notify the resident's physician and responsible party of a change in condition for 1 of 3 residents (Resident #1) reviewed. This deficient practice was evidenced by the following:On 10/27/2025 at 8:30 AM, the surveyor reviewed the closed medical record for Resident #1.A review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues).A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/7/2025, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition.A review of the corresponding Medication Administration Record (MAR) revealed that the resident's temperature on 2/24/2025, during an unspecified time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: 407581Based on interviews, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that medication was administered and documented according to a physician order. This deficient practice was identified for 1 out of 3 residents reviewed for quality of care (Resident #1). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 10/27/2025 at 8:30 AM, the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 168449 Based on observation, interview, record review, and review of facility provided documents it was determined that the facility failed to consistently provide appropriate and timely incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs) care. This deficient practice was identified for 2 of 3 residents (Resident #3 and #184) reviewed for ADL care and was evidenced by the following: 1. On 10/21/24 at 8:20 AM, the surveyor conduced an initial tour of the [NAME] Unit and observed a strong urine odor in the hallway. On 10/21/24 at 8:21 AM, the surveyor observed Resident #3 in bed in their room. The surveyor inquired regarding the care received at the facility, and Resident #3 stated that they were soiled and needed to be changed. The resident, then activated the call light, and stated that staff took a long time to answer the call light. Resident #3 stated sometimes it could take one hour for staff to answer the call light and incontinence care was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure a system was in place to ensure a resident with a pressure ulcer, who was dependent on staff for care, was turned and repositioned. This deficient practice was identified for 1 of 1 resident (Resident #56) reviewed for care and services for pressure ulcers and was evidenced by the following: On 10/21/2024 at 8:32 AM, the surveyor observed Resident #56 lying in bed on their back on a scoop type mattress (a mattress with a concave center) and a Certified Nursing Aide (CNA) was assisting the resident with breakfast. CNA #1 stated that she was not too sure about the resident but knew there was a wound dressing on the resident's hip. On 10/22/2024 at 9:48 AM, the surveyor observed Resident #56 lying on their back in bed on a scoop mattress with a fall mat on one side and the bed pushed against one wall. On 10/23/2024 at 9:05 AM, the surveyor, again, observed Resident #56 lying on their back in bed on a scoop mattress. At 10:01, CNA #2 was in the room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to follow the Facility Assessment and facility policy to ensure that staff were educated to care for residents who required hemodialysis and had different types of access sites. The deficient practice was identified for 2 of 2 residents reviewed for dialysis (Resident #57 and #185) and was evidenced by the following: A review of the facility provided, Facility Assessment dated 2023-2024, included but was not limited to; Requirement . resident population and the resources our facility needs to care for our residents as per the recommended guidelines: The facility assessment must address or include: (1) the facility's resident population, including, but not limited to, . b. the care required by the resident population considering the types of diseases, conditions, physical, and cognitive disabilities, overall acuity, and other pertinent facts that are present with in that population; c. the staff competencies that are necessary to provide the level and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that the facility failed to follow a physician order for a treatment to treat a moisture associated dermatitis identified on 10/21/24. This deficient practice was identified for 1 of 21 residents reviewed (Resident #3) for quality of care and was evidenced by the following: On 10/21/24 at 8:45 AM, with the Certified Nursing Assistant (CNA) present and observed that Resident #3, a CNA #2 entered the room to provide incontinence care to Resident #3. The surveyor observed that the incontinence brief was bulging from the front to the back, and Resident #3 was wearing two incontinent briefs which were both saturated with urine and feces. The surveyor observed that the bed pad was yellow stained. CNA #2 then informed the surveyor that she had not yet provided care to the resident had visible redness on the groin and buttocks areas. The concerns were reported to the Registered Nurse (RN) Unit Manager (UM) who then generated a wound consult for Resident #3. On 10/23/24 at 11:00 AM, the surveyor reviewed the medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to consistently perform hand hygiene to prevent the spread of potential infection. This deficient practice was identified for 1 of 2 licensed nurses observed during the medication administration observation, and for 2 staff members observed assisting during the meal service and was evidenced by the following: 1. On 10/22/24 at 8:27 AM, Surveyor #1 observed a Licensed Practical Nurse (LPN) during the medication administration pass. The LPN was observed to enter a resident bathroom, turn on the water, applied soap to her hands, and washed her hands under the stream of water for 12 seconds. Next, the LPN dried her hands and used a paper towel to turn off the water. On 10/22/24 at 8:53 AM, the same LPN was observed in another resident bathroom. She turned on the water, applied soap, applied friction for 8 seconds outside the flow of water and next proceeded to wash her hands for 13 seconds under the flow of water. On 10/22/24 at 9:09 AM, the LPN stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview on 10/22/2024 in the presence of the Director of Maintenance (DOM) and Assistant Administrator (AA), it was determined that the facility failed to ensure that the call bell system was properly functioning in 1 of 5 tested rooms and was evidenced by the following: An observation at 1:45 PM revealed, the call bell button for room [ROOM NUMBER] window bed did not function when tested by the DOM. The facility's Assistant Administrator was informed of the deficient practice at the Life Safety Code exit conference at 1:30 PM. N.J.A.C 8:39-31:2(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment that accommodated resident needs and preferences. This deficient practice was identified for 1 of 22 residents reviewed (Resident #59) and was evidenced by the following: On 6/6/23 at 10:46 AM, the surveyor observed Resident #59 attempting to navigate their room. Resident #59's bed was located closest to the door. Due to their height, the resident's bed was adapted with a detachable foot extension. In order to get to the opposite side of the bed, the surveyor observed Resident #59 remove the bed extension, self-propel backwards in their wheelchair past the foot of the bed, then reattach the extender. The surveyor reviewed the medical record for Resident #59. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in July of 2020, with diagnoses which included cerebral infarction (stroke) and hemiplegia (paralysis of one side of the body). A review of the most recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain medication carts free from unmarked and unwrapped medications and b.) accurately document the administration of controlled medications on the Controlled Drug Administration Record Tablet (declining inventory sheet) for an unsampled resident. This deficient practice was identified for 1 of 2 medication carts on 1 of 2 nursing units ([NAME] low- side) and was evidenced by the following: On 6/6/23 at 12:53 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the [NAME] nursing unit's low-side medication cart and observed the following: 1. Inside the top drawer on the right side of the medication cart, a small plastic medication cup which contained two unmarked tablets. At this time, the LPN identified the tablets as an iron supplement and repaglinide (diabetic medication) that she had just poured into the cup for an unsampled resident and meant to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 6/6/23 at 10:01 AM, the surveyor toured the kitchen with the Food Service Director (FSD). The surveyor observed the following: In the meat kitchen hanging above the tray serving line on a utensil rack, one large and one medium rubber spatula. The spatulas were both cracked and discolored, and the medium rubber spatula was missing rubber in parts. The FSD confirmed the spatulas should not be in use. In the dairy kitchen hanging above the tray serving line on a utensil rack, one large rubber spatula cracked and discolored. The FSD confirmed the spatula should not be in use. On a rack, two large white, one medium green, one medium yellow, and one medium red cutting boards all discolored and pitted. There was also a tan rubber cutting board discolored black. The FSD stated cutting boards were changed as needed and she had not changed the cutting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary environment for 3 of 50 residents' rooms for hand sinks (Resident room [ROOM NUMBER], #17, and #23). The deficient practice was evidenced by the following: On 6/6/23 at 9:32 AM, the surveyor observed in Resident room [ROOM NUMBER], the cabinet sink in the bathroom was in a state of disrepair. The front of the cabinet had missing laminate covering that had exposed the particle board. The doors to the cabinet were misaligned, had a missing handle, and the laminate covering was missing, which exposed the particle board on the doors. On 6/6/23 at 10:45 AM, the surveyor observed in Resident room [ROOM NUMBER], the molding in the front of the hand sink was missing and the wood was separated, exposing the particle board. The vertical molding of the sink was missing exposing the wood from the sink to the floor. On 6/623 at 11:34 AM, the surveyor observed in Resident room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/06/21 from 11:28 AM until 11:48 AM, during a follow-up visit to the kitchen, the surveyor observed the following in the presence of the Food Service Director (FSD): 1. The surveyor observed the [NAME] who wore a hair net that did not completely cover her hair as she prepared to obtain food temperatures from the steam table. When interviewed, she stated that her hair was supposed to be fully covered because she could possibly contaminate the food. 2. The surveyor observed that the Dietary Aide wore a hair net that did not completely cover her hair as she obtained food from the reach-in refrigerator located in the galley of the kitchen. She stated that everyone knew that their hair was supposed to be fully covered. When interviewed, the FSD stated that both the [NAME] and the Dietary Aide were required to ensure that their hair was fully covered.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.