King Manor Care and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure staff provided care in a manner for residents to attain their highest practicable physical and psychosocial well-being by ensuring processes were put in place a.) to identify a change in condition in a timely manner, b.) to assess any decline in the functional status of a resident (Resident #58) who required assistance with bathing and was not provided a shower for over three months, and c.) to ensure a recommended physician follow-up appointment was scheduled. On 3/25/26, Resident #58 asked the surveyor to assist them in obtaining a shower, who was then showered, and the resident had a skin assessment completed by the physician who identified bilateral lower extremity cellulitis (infection) that required antibiotic treatment. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to a.) provide adequate supervision and implement targeted interventions to prevent falls for a resident (Resident #58) who sustained six falls between 12/5/25 and 2/26/26, including multiple unwitnessed falls and three falls that required hospitalization. On 2/8/26, Resident #58 sustained a right periorbital hematoma (bruising and swelling of the tissue around the eye) with a 2-centimeter laceration to the right eyebrow from an unwitnessed fall. This deficient practice was identified for 1of 2 residents reviewed for falls (Resident #58). [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to have a system in place to ensure quarterly financial statements were provided to residents who maintained Personal Needs Account (PNA) funds with the facility. This deficient practice was identified for 7 of 7 residents who attended a resident council meeting, and affected all 84 residents identified as maintaining a facility PNA account. The evidence was as follows: On 3/23/26 at 8:13 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of all Personal Need Account balances as of 3/19/26. The Trial Balance listed 84 total PNA accounts with a $33,770.89 balance held by the facility. On 03/23/26 at 10:28 AM, the surveyor conducted a resident council meeting with 7 residents. [...]

Inspectors wroteBased on observation interview and document review it was determined that the facility failed to ensure a process was in place to ensure that all residents that maintained a Personal Needs Account (PNA) that approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI) were notified. This deficient practice was identified for a resident who had PNA funds in excess of $2000.00 (Resident #56) and affected all 84 residents who maintained a facility PNA. The evidence was as follows: On 3/23/26 at 8:13 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of all Personal Need Account balances as of 3/19/26. Resident #56 had a current balance of $2036.12, and the Trial Balance listed 84 total accounts with a $33,770.89 balance held by the facility. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that there was sufficient competent staff to ensure a) all residents were provided with appropriate and timely incontinence care, nail care and were consistently available to provide appropriate care to maintain residents highest practicable physical, mental, and psychosocial wellbeing and b) the minimum staffing requirements per the New Jersey Department of Health based on acuity of the residents was maintained. The deficient practice was identified for 5 of 5 residents reviewed (Resident #10, #31, # 58, #68 and #122) and had the potential to affect all residents who resided in the facility. The evidence was as follows: Refer to F677a)1. [...]

Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of all Certified Nursing Aides (CNA) to provide specific education aligned with the facility assessment and based on staff observed needs for improvement. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed, and was evidenced by the following:On 3/24/26 at 10:30 PM, the surveyor requested the Licensed Home Administrator (LNHA) to provide the list of all new hires since the last survey, including employees who were no longer employed by the facility and contracting facility's employees. On 3/24/26 at 10:00 AM, the surveyor interviewed the Nurse educator and required the orientation package, the facility assessment and the Performance Evaluation for 5 selected CNAs. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that it maintained responsibility for the care and services provided to residents at all times, and ensure a process was in place to integrate care and services for residents who regularly attended an outside Program of All -Inclusive Care of the Elderly (PACE). This deficient practice was identified for 1 of 3 residents reviewed for accidents (Resident #115) and attended a PACE program, and had the potential to affect all residents who resided in the facility and for 6 of 6 residents who attended a PACE program. The evidence was as follows: [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to have a process in place to ensure that prior to signing a binding arbitration agreement, that was included within the admission Packet, the agreement was clearly communicated to the resident or representative in a manner they understood, and they acknowledged they understood the agreement. The deficient practice was identified for 7 of 7 residents (Resident #15, #37, #38, #86, #102, #106, and #114) who attended a resident council meeting and a resident with a severely impaired cognition (Resident #105). The evidence was as follows: On 3/22/26 at 10:19 AM, during the facility entrance conference held with the Licensed Nursing Home Administrator (LNHA), the surveyor asked the LNHA if the facility used Arbitration Agreements and asked if any residents had signed the agreements. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility Quality Assurance and Performance Improvement (QAPI) committee failed to self-identify systems and processes that may negatively affect resident quality of care, quality of life and review significant events and implement data driven QAPI program. The deficient practice affected all residents who resided at the facility and was evidenced by the following: Refer to F568, F569, F584, F677, F679, F684, F689, F730, F925Refer to F568, F569, F584E, F677E, F679E, F684H, F689H, F730F, F925E a. On 3/23/26 at 8:13 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of all Personal Need Account balances as of 3/19/26. Resident #56 had a current balance of $2036.12, and the Trial Balance listed 84 total accounts with a $33,770.89 balance held by the facility. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the facility Performance Improvement Plan (PIP) to follow the facility process to measure and utilize data acquired and develop quantitative and measurable goals, this deficient practice was evidenced by the following:On 3/24/2026 at 11:00 AM, the surveyor reviewed facility provided Performance Improvement Plans (PIPs) for activities regarding resident participation, missed reimbursement related to failure to capture respiratory treatments, CNA staffing, MDS modifications, and baseline care plans. All PIPs reviewed did not include quantitative and measurable goals. In addition, there were no goals and thresholds listed for performance measurements. [...]

Inspectors wroteComplaint # NJ 2577317 Based on observation, interview and document review, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable and homelike manner for 4 of 4 resident rooms (#1, #13, #15 and #19) observed on 1 of 2 resident units (Rosewood), and for 1 of 2 shower rooms ([NAME]). The evidence was as follows: a. On 3/22/26 at 10:40 AM, during the initial tour, the surveyor entered Residents room [ROOM NUMBER]'s bathroom, observed broken tiles behind the toilet, four (4) of the 9 ceiling tiles had gaps which also surrounded the sprinkler head ,were deteriorated on the corners of the tiles, a plywood on top of the bathtub which was not fastened, and was covered with half a mat, positioned lengthwise. At that time, the surveyor invited the Certified Nurse Aide (CNA) to enter room [ROOM NUMBER]'s bathroom. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents who were dependent on staff for activities of daily living was provided with a) routine and appropriate incontinence care, b) a shower that was consistent with their needs and preferences, c) assistance to get out of bed, d) routine and appropriate nail care in a timely manner This deficient practice was identified for 4 of 4 residents reviewed for activities of daily living (Resident #10, Resident #31, Resident # 58 and Resident #122). The evidence was as follows:1) On 3/22/26 at 8:30 AM, the surveyor #1 entered Resident #122's room and observed Resident #122 in bed. Upon inquiry, Resident #122 informed the surveyor that they were not provided with incontinence care on the 11:00 PM-7:00 AM shift. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a process was in place to provide an ongoing program to support a resident's individual activity preferences to support the psychosocial needs of the residents. The deficient practice was identified for 1 of 1 resident (Resident # 56) reviewed for activities and was evidenced by the following: On 03/24/26 at 10:39 AM, the surveyor interviewed Resident #56 and asked Resident #56 regarding what they liked to do for activities, and Resident #56's regular certified nurse aide was also present. The resident stated they loved jewelry and showed the surveyor their earrings. When asked if the resident attended the trips, the resident stated they were never asked about the trips and would go on trips. [...]

Inspectors wroteRefer to 759. Based on observation, interview, and record review, it was determined that the facility failed to ensure the recommendation made by the Consultant Pharmacist (CP) was acted upon in a timely manner for one (1) of two (2) residents (Resident #95) with a physician ordered diet of nectar thickened liquid and was evidenced by the following: On 3/23/26 at 9:45 AM, the surveyor began the Medication Observation Pass for Resident #95. The Licensed Practical Nurse (LPN) began to prepare the medication that included a physician order (PO) of Levetiracetam (Keppra) oral solution 500 milligram (mg)/5 milliliter (ml); give 10 ml by mouth every 12 hours for seizures. The order started on 12/27/25 and scheduled for administration at 9:00 AM. No additional instruction was reflected on the PO. [...]

Inspectors wroteRefer to 756. Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 3/23/26 and 3/24/26, the surveyor observed six (6) nurses administer medications to six (6) residents. There were 26 opportunities, and three errors were observed which resulted in a medication error rate of 7.69%. This deficient practice was identified for two (2) of six (6) residents (Resident #84 and #95), that was administered by two (2) of six (6) nurses. This deficient practice was evidenced by the following:a. On 3/23/26 at 8:46 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare medications for Resident #84. The medications included a physician's order (PO) of Aspercreme with Lidocaine Cream 4% (Lidocaine); [...]

Inspectors wroteComplaint NJ #2743500Based on observation, interview and document review, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of cockroaches. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following:On 3/22/26 at 8:57 AM, Resident #54 approached surveyor and stated that they had been in the facility approximately two months and they resided in the third room since they had been admitted . The resident then proceeded to show the surveyor a plastic bag with 4 dead cockroach- like insects inside. Resident #54 then informed the surveyor the dead bugs were cockroaches. The resident then stated that when they used the bathroom during the night, and then turned on the light, they would see the cockroaches scatter. [...]

Inspectors wroteBased on observation, interview and review of facility's documentation, the facility failed to ensure that medications were administered according to standards of practice. This deficient practice was identified for 1 of 1 resident observed with medication left unattended at the bedside (Resident #58). The evidence was as follows: On 3/22/26 at 10:00 AM the surveyor entered Resident #58's room and observed a medication cup with 6 tablets inside the cup and a cup of water on the bedside table. The surveyor observed the resident seated in the room by the bed. Upon inquiry, the resident informed the surveyor that the nurse left the medications at the bedside for them to take. The surveyor exited the room at 10:28 AM, and the medications were still at the bedside. The surveyor did not observe any other residents wandering in the hallway. [...]

Inspectors wroteComplaint #: 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). [...]

Inspectors wroteComplaint #: 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; [...]

Inspectors wroteComplaint # 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]