Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at King Manor Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions developed a fever, but staff failed to document follow-up actions or notify the physician and responsible party as required by facility policy. Nursing staff interviews confirmed that the expected protocol was not followed, resulting in a deficiency related to notification and documentation of a significant change in condition.
A resident with severe cognitive impairment and multiple medical conditions did not receive acetaminophen as ordered for a documented fever, and there was no documentation of medication administration, follow-up monitoring, or nursing assessment. Facility staff interviews and policy review confirmed that required protocols for medication administration and documentation were not followed.
Two residents in a facility did not receive timely incontinence care, leading to prolonged periods of being soiled. One resident was found wearing two saturated briefs, and staff were unaware of this practice. Another resident experienced issues with a Condom Catheter, resulting in frequent wetness due to improper application and delayed care. The facility's policy on ADLs was not followed, as care was not documented or provided consistently.
A facility failed to implement a turning and repositioning program for a resident with pressure ulcers, who was dependent on staff for care. Despite the resident's high risk for pressure sores and a care plan requiring repositioning every 2-3 hours, there was no documentation of these interventions being followed. Staff interviews confirmed the lack of adherence to the care plan, and the facility's policy on pressure ulcer prevention was not implemented.
The facility failed to ensure staff were trained and competent in caring for residents requiring hemodialysis, specifically in assessing different dialysis access sites. Two residents with dialysis needs were affected, as staff did not perform required checks on their access sites due to a lack of training. The facility's policy required trained staff for such tasks, but this was not implemented, leading to the deficiency.
A resident with Moisture-Associated Skin Damage (MASD) did not receive the prescribed Nystatin cream treatment due to a failure to transcribe the physician's order onto the Treatment Administration Record (TAR). The resident was observed with saturated incontinence briefs and reddened skin, and the treatment was not administered for several days. The DON and AA were unaware of the oversight until informed by the survey team.
The facility was found deficient in hand hygiene practices, as observed during a survey. An LPN washed hands for insufficient durations during medication administration, and both a DA and a CNA failed to perform hand hygiene between resident interactions during meal service. Despite having completed hand hygiene competency validations, their actions did not align with the facility's policy, which mandates handwashing before and after contact with residents, equipment, and food.
The facility failed to maintain a functioning call bell system in one of the tested rooms. During an observation, the call bell button for a resident's window bed was found non-functional when tested by the DOM. This issue was identified in the presence of the DOM and AA and communicated during the Life Safety Code exit conference.
Failure to Notify Physician and Responsible Party of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia, experienced a change in condition marked by a fever of 100.2°F. The resident, who had severely impaired cognition as indicated by a BIMS score of 3 out of 15, had this elevated temperature recorded on the Medication Administration Record (MAR) during the 11-7 shift. However, there were no corresponding nursing notes, no follow-up temperature checks, and no documentation of any actions taken in response to the fever during that shift. Further review revealed that neither the resident's physician nor the responsible party was notified of the fever, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the expected protocol in such situations includes documenting the event, monitoring the resident, notifying the physician and family, and administering Tylenol if indicated. The facility's policies also require documentation of all services provided and notification of significant changes in a resident's condition. These steps were not followed in this instance, resulting in a failure to notify the appropriate parties of the resident's change in condition.
Failure to Administer and Document PRN Medication for Fever
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia, did not receive treatment and care in accordance with physician orders and professional standards. The resident, who had severely impaired cognition as indicated by a BIMS score of 3 out of 15, had a physician's order for acetaminophen 650 mg to be administered orally every 4 hours as needed for a temperature of 100°F or above, with a maximum daily dose of 3 grams. On a specific shift, the resident's temperature was recorded at 100.2°F, but there was no documentation that acetaminophen was administered, nor were there any nursing administration signatures on the MAR for that shift and the following one. Additionally, there were no nursing notes, follow-up temperature checks, assessments, or monitoring documented in the medical record after the fever was noted. Interviews with nursing staff and the DON confirmed that the expected protocol would be to administer acetaminophen, monitor the resident, document all actions, and notify the physician and family as appropriate. Facility policies also required documentation of all services provided, including medication administration and any changes in the resident's condition. These actions and inactions led to the identified deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for residents dependent on staff for Activities of Daily Living (ADLs). Resident #3 was observed in bed with a strong urine odor in the hallway. The resident reported being soiled and needing to be changed, stating that staff took a long time to respond to call lights, sometimes up to an hour. The surveyor observed that the resident was wearing two saturated incontinence briefs, which were not changed promptly. The care plan for Resident #3 did not specify the frequency of incontinence care, and the staff was unaware of the use of double briefs, which could lead to skin irritation. Resident #184 also experienced delays in receiving incontinence care. The resident, who wore a Condom Catheter (CC), reported that staff did not know how to apply it properly, leading to frequent dislodgement and wetness. The resident stated that staff sometimes took 4 to 5 hours to respond, resulting in prolonged periods of being soaked with urine. The surveyor confirmed that the resident's gown and brief were soaked, and the CNA did not check the resident before serving breakfast. The electronic record for ADL tasks was left blank for two consecutive days, indicating a lack of documentation of care provided. The facility's policy on Activities of Daily Living (ADL) Supporting, last revised in 2018, stated that residents unable to carry out ADLs independently would receive necessary services to maintain good hygiene. However, the facility failed to adhere to this policy, as evidenced by the lack of timely incontinence care for Residents #3 and #184. The Registered Nurse/Unit Manager (RN/UM) was unaware of the use of double briefs and stated that incontinence care should be provided every two hours, which was not consistently done.
Failure to Implement Turning and Repositioning Program for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure a system was in place for turning and repositioning a resident with pressure ulcers, who was dependent on staff for care. The deficiency was identified for a resident who was observed multiple times lying on their back in bed on a scoop mattress, with no documentation of being turned or repositioned. Certified Nursing Aides (CNAs) were aware of the resident's wound dressing but did not have documentation to confirm that the resident was being turned every two hours as required. The resident's medical record revealed multiple diagnoses, including toxic encephalopathy, muscle weakness, and osteoporosis, and indicated the presence of pressure ulcers at various stages. The care plan included interventions such as turning and repositioning every 2-3 hours, but there was no evidence of these interventions being documented or followed. The resident was assessed as being at very high risk for pressure sores, with a Braden Scale score of 8, yet the facility failed to implement a documented turning and repositioning program. Interviews with facility staff, including the Registered Nurse, Director of Nursing, and Rehabilitation Director, confirmed the lack of documentation and adherence to the care plan. The facility's policy on pressure ulcer prevention required repositioning at least every two hours for residents who are bed-bound and dependent on staff, but this was not followed for the resident in question. The Assistant Licensed Nursing Home Administrator acknowledged the absence of a documented turning and repositioning schedule for the resident.
Inadequate Staff Training for Dialysis Care
Penalty
Summary
The facility failed to ensure that staff were adequately trained and competent in the care of residents requiring hemodialysis, specifically in the assessment and care of different types of dialysis access sites. This deficiency was identified for two residents who required dialysis. Resident #185, who had a Permacath for dialysis, was observed and reported that staff were supposed to check for a bruit at the access site, as per the medical orders. However, RN #1, responsible for monitoring the Permacath, admitted to not having received competency training for assessing the Permacath and incorrectly stated that a bruit should be checked for a Permacath, which is not standard practice. Similarly, Resident #57, who had an arteriovenous fistula (AVF) for dialysis, reported that facility staff did not check their dialysis site. The medical record indicated that staff were required to check the AVF for a bruit and thrill every shift. RN #2, responsible for monitoring this resident, also admitted to not having received competency training for the assessment and care of the AVF. The facility's policy on hemodialysis catheters stated that only trained and competent medical staff should access these catheters, but this was not adhered to. The Assistant Licensed Nursing Home Administrator confirmed that the facility did not have nurse competencies for the assessment and care of hemodialysis accesses. The facility's failure to provide necessary training and ensure staff competency in the care of dialysis access sites led to the deficiency, as staff were not adequately prepared to perform the required assessments and care for residents with hemodialysis needs.
Failure to Administer Prescribed Treatment for Skin Condition
Penalty
Summary
The facility failed to follow a physician's order for treating a resident diagnosed with Moisture-Associated Skin Damage (MASD). The deficiency was identified when a surveyor observed that the resident was wearing two saturated incontinence briefs, and the bed pad was stained. The resident had visible redness on the groin and buttocks areas, which was reported to the RN Unit Manager, leading to a wound consult. The wound practitioner diagnosed the resident with MASD and ordered Nystatin cream to be applied to the affected areas every shift after washing and drying the area. However, the order was not transcribed onto the Treatment Administration Record (TAR), and the resident did not receive the prescribed treatment on multiple occasions. Further investigation revealed that the order from the wound practitioner was not located on the TAR, and the resident continued to be observed with soiled briefs and reddened skin. The Director of Nursing (DON) and the Assistant Administrator (AA) were unaware that the treatment had not been administered as ordered. The AA later informed the survey team that the Unit Manager failed to transcribe the order, resulting in the resident not receiving the necessary treatment for several days.
Inconsistent Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to consistently perform hand hygiene to prevent the spread of potential infection, as observed during a survey. One Licensed Practical Nurse (LPN) was observed washing hands for insufficient durations during medication administration, contrary to the facility's policy which requires handwashing for at least 20 seconds. The LPN admitted to not following the correct procedure, which involves applying friction for 20-30 seconds outside the stream of water. The facility's documentation indicated that the LPN had previously been observed successfully performing hand hygiene, yet the observed practice did not align with the established guidelines. Additionally, the Director of Activities (DA) and a Certified Nursing Aide (CNA) were observed failing to perform hand hygiene between resident interactions during meal service. The DA handled a portable oxygen tank and distributed drinks without washing hands, while the CNA did not perform hand hygiene after removing gloves and before assisting residents with meals. Both staff members acknowledged the importance of hand hygiene and the facility's policy, which mandates handwashing before and after contact with residents, equipment, and food. Despite having completed hand hygiene competency validations, their actions during the survey did not reflect adherence to these standards.
Deficient Call Bell System in Resident's Room
Penalty
Summary
The facility failed to ensure that the call bell system was properly functioning in one of the five tested rooms. During an observation at 1:45 PM, it was revealed that the call bell button for the window bed in the specified room did not function when tested by the Director of Maintenance. This deficiency was identified in the presence of the Director of Maintenance and the Assistant Administrator and was communicated to the facility's Assistant Administrator during the Life Safety Code exit conference.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Neptune
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coral Harbor Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 0.9 mi | ★★★★★ | 0 | 0 |
| Complete Care At Ocean Grove Llc | 1.4 mi | ★★★★★ | 1 | 0 |
| Imperial Care Center | 1.7 mi | ★★★★★ | 17 | 0 |
| Continuing Care At Seabrook | 2.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.