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.
Resident Activity Programs Inadequately Documented
The facility failed to provide comprehensive activity programs for residents with cognitive impairments and did not maintain proper documentation of resident participation. Two residents with severe cognitive impairment lacked appropriate activity assessments and programming.
One resident who spoke only Spanish had an activity evaluation indicating they spoke English, and no Spanish-language activities were documented in their care plan. The Activities Director was unable to explain this discrepancy or provide information about culturally appropriate programming.
For residents with dementia and other cognitive impairments, meaningful activities are essential for maintaining quality of life, reducing behavioral symptoms, and promoting social engagement. Federal regulations require nursing homes to provide activities that meet each resident's interests and functional capacity.
The facility maintained inconsistent documentation of resident participation and had no system for tracking whether residents were offered activities or declined to participate. Activity calendars posted throughout the building failed to include times or locations, making it difficult for residents and families to plan participation.
Call Bell System Malfunctions Prevented Emergency Response
Critical communication failures left multiple residents unable to summon help during emergencies. Inspectors found call bell systems malfunctioning across multiple resident rooms, with some systems showing connectivity errors and others completely unplugged at nursing stations.
When tested, call bells in several rooms failed to send activation signals to nursing stations. In one case, maintenance staff discovered the annunciator cord wasn't properly connected. In another instance, the entire system was unplugged and powered off, preventing any emergency communications from that unit.
Functioning call bell systems are the primary method for residents to request assistance during medical emergencies, falls, or other urgent situations. When these systems fail, residents may be unable to receive timely help, potentially leading to serious injuries or preventable complications.
Additional Issues Identified
Beyond these major violations, inspectors documented several other deficiencies affecting resident care and safety. The facility's medication storage and labeling practices required improvement to ensure proper pharmaceutical management. Environmental cleanliness standards needed enhancement to prevent potential infection transmission.
Staff training records showed completion of required infection control education, but observed practices demonstrated gaps between training and implementation. Several policies lacked specific procedures or had not been updated to reflect current standards of care.
The facility administration was notified of all violations during the inspection process and given opportunities to provide additional information or corrective actions. These violations represent serious departures from federal nursing home standards designed to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care One At King James from 2025-01-10 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.