Care One at King James: Safety Violation Found, NJ
ATLANTIC HIGHLANDS, NJ - Federal inspectors documented serious safety and care deficiencies at Care One At King James nursing facility during a January 2025 inspection, including emergency equipment failures, infection control lapses, and inadequate resident activity programs.
Emergency Equipment Compromised Patient Safety
Inspectors discovered significant problems with emergency crash carts across all three resident units, potentially compromising life-saving care during medical emergencies. The facility lacked any written policy or procedure for staff to inspect these critical emergency carts, leaving nursing staff without clear guidance on what to check or how often.
During the inspection, surveyors found expired medical supplies in multiple emergency carts. In one cart, a resuscitation bag had expired in November 2024 and two IV insertion kits had expired in October 2024. These supplies are essential during cardiac arrests and other medical emergencies where seconds matter.
The emergency cart checklists were incomplete and lacked proper instructions. Staff were signing off on daily checks without actually inspecting the contents or verifying expiration dates. The Licensed Practical Nurse Infection Preventionist confirmed that "the checklist should be checked and signed daily" but acknowledged there was no reason why proper checks weren't being performed.
Emergency crash carts contain life-saving medications and equipment used during cardiac arrests, respiratory failures, and other critical situations. When supplies are expired or missing, medical teams cannot provide optimal care during emergencies. Professional standards require daily inspection of all emergency equipment to ensure proper function and availability.
The facility's administrator acknowledged that staff were signing checklists "but there was no procedure for them to follow regarding what to check for." Even after being notified of the issues, the facility's replacement checklist still failed to include inspection of the resuscitation bag.
Infection Control Failures Created Disease Transmission Risks
Multiple infection control violations increased the risk of disease transmission among vulnerable residents. Staff repeatedly failed to follow Contact Isolation precautions for a resident with HSV-1, a highly contagious viral infection.
Inspectors observed a certified nursing assistant entering an isolation room without required protective equipment. When questioned, the aide initially stated she "just went to drop off the lunch tray and did not have to put on PPE," but later acknowledged "I should have put it on as per the signage" after reading the posted requirements.
Contact isolation protocols require all staff to wear gowns and gloves before entering a resident's room to prevent transmission of infectious diseases. The signage clearly stated "Everyone must: Put on gloves before room entry. Put on gown before room entry."
A second violation involved improper catheter care. Surveyors found a resident's urinary drainage bag resting on the floor for over an hour, creating significant infection risk. Urinary catheters must be kept sterile, and drainage bags should never touch the floor due to contamination concerns.
Catheter-associated urinary tract infections are among the most common healthcare-associated infections, often leading to serious complications including bloodstream infections and sepsis in elderly residents. Proper catheter positioning is a basic infection prevention measure that requires drainage bags to remain below bladder level and secured to bed frames.
Staff also failed to perform hand hygiene when moving between isolation rooms during meal service, potentially spreading infectious agents to other vulnerable residents.
Kitchen Sanitation Problems Threatened Food Safety
The facility's kitchen environment posed multiple food safety risks that could lead to foodborne illness outbreaks. Inspectors documented several serious sanitation violations during their kitchen tour with the Food Service Director.
The exhaust hood baffles above cooking equipment were heavily soiled with black debris, grease, and grime. These components are critical for removing cooking vapors and preventing grease buildup that creates fire hazards. The facility's own policy required monthly cleaning of these components, but the Food Service Director admitted to working on developing a cleaning schedule.
The kitchen's only hand washing sink failed to provide adequately heated water. Water temperature measured only 74 degrees Fahrenheit, well below the required 90-110 degree range specified in the facility's posted signage. The Food Service Director acknowledged that "cold water won't take off bacteria," demonstrating awareness of proper food safety principles while failing to ensure compliance.
Additional violations included food service equipment stored in unsanitary conditions, with insulated tray lids stacked unprotected under visibly soiled surfaces.
Proper kitchen sanitation is essential in nursing homes where residents often have compromised immune systems and underlying health conditions that make them particularly vulnerable to foodborne illnesses. Temperature control, surface sanitation, and equipment cleaning are fundamental food safety requirements.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 30, 2026 · Our methodology
CAREONE AT MIDDLETOWN in ATLANTIC HIGHLANDS, NJ was cited for violations during a health inspection on January 10, 2025.
During the inspection, surveyors found expired medical supplies in multiple emergency carts.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.