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CENTERS FOR MEDICARE & MEDICAID SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES

POST-CERTIFICATION REVISIT REPORT

STREET ADDRESS, CITY, STATE, ZIP CODE

B. Wing Y1

DATE OF REVISIT

A. Building

315087

NAME OF FACILITY

MULTIPLE CONSTRUCTIONPROVIDER / SUPPLIER / CLIA /

IDENTIFICATION NUMBER

CARE ONE AT KING JAMES 1040 ROUTE 36

ATLANTIC HIGHLANDS, NJ 07716

6/21/2019 Y2 Y3

This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments

program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been

corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC

provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on

the survey report form).

Y4

ITEM

Y5

DATE

Y4

ITEM

Y5

DATE DATE

Y5

ITEM

Y4

ID Prefix F0761 Correction

Reg. # 483.45(g)(h)(1)(2)

Completed

LSC 06/21/2019

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

REVIEWED BY

STATE AGENCY

REVIEWED BY

CMS RO

REVIEWED BY

(INITIALS)

REVIEWED BY

(INITIALS)

DATE

DATE SIGNATURE OF SURVEYOR

TITLE DATE

DATE

FOLLOWUP TO SURVEY COMPLETED ON CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF

UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO6/7/2019

Form CMS - 2567B (09/92) EF (11/06) Page 1 of 1 TIYL12EVENT ID:

CENTERS FOR MEDICARE & MEDICAID SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES

POST-CERTIFICATION REVISIT REPORT

STREET ADDRESS, CITY, STATE, ZIP CODE

B. Wing Y1

DATE OF REVISIT

A. Building

315087

NAME OF FACILITY

MULTIPLE CONSTRUCTIONPROVIDER / SUPPLIER / CLIA /

IDENTIFICATION NUMBER 01 - MAIN BUILDING 01

CARE ONE AT KING JAMES 1040 ROUTE 36

ATLANTIC HIGHLANDS, NJ 07716

6/21/2019 Y2 Y3

This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments

program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been

corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC

provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on

the survey report form).

Y4

ITEM

Y5

DATE

Y4

ITEM

Y5

DATE DATE

Y5

ITEM

Y4

ID Prefix Correction

Reg. # NFPA 101

Completed

LSC 06/21/2019K0321

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

ID Prefix Correction

Reg. # Completed

LSC

REVIEWED BY

STATE AGENCY

REVIEWED BY

CMS RO

REVIEWED BY

(INITIALS)

REVIEWED BY

(INITIALS)

DATE

DATE SIGNATURE OF SURVEYOR

TITLE DATE

DATE

FOLLOWUP TO SURVEY COMPLETED ON CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF

UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO6/7/2019

Form CMS - 2567B (09/92) EF (11/06) Page 1 of 1 TIYL22EVENT ID:

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 06/07/2019 STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

STANDARD SURVEY: 6/7/2019

CENSUS: 99

SAMPLE SIZE: 21 (Plus 3 Closed Records)

The facility is not in substantial compliance with

the requirements of 42 CFR Part 483, Subpart B,

for long term care facilities.

F 761

SS=D

Label/Store Drugs and Biologicals

CFR(s): 483.45(g)(h)(1)(2)

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility must be

labeled in accordance with currently accepted

professional principles, and include the

appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and

Federal laws, the facility must store all drugs and

biologicals in locked compartments under proper

temperature controls, and permit only authorized

personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately

locked, permanently affixed compartments for

storage of controlled drugs listed in Schedule II of

the Comprehensive Drug Abuse Prevention and

Control Act of 1976 and other drugs subject to

abuse, except when the facility uses single unit

package drug distribution systems in which the

quantity stored is minimal and a missing dose can

be readily detected.

F 761 6/12/19

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

06/21/2019Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete TIYL11Event ID: Facility ID: NJ61315 If continuation sheet Page 1 of 4

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 06/07/2019 STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 761 Continued From page 1 F 761

This REQUIREMENT is not met as evidenced

by:

Based on observation, interview and record

review, it was determined that the facility failed to

properly store and label medications in 1 of 3

medication storage rooms and 1 of 4 medication

carts inspected.

This deficient practice was evidenced by the

following:

On 06/04/19 at 11:42 a.m., the surveyor

inspected the medication storage room

and refrigerator in the presence of the License

Practical Nurse (LPN) Unit manager (UM) and

observed the following:

1. The medication refrigerator temperature read

50 degrees Fahrenheit (F). A review of the

Refrigerator Temperature Log (RTL) dated June

2019, revealed that on 06/03/19, the refrigerator

temperature was 48 degrees F. Further review of

the RTL, under the corrective action column

revealed no documentation of corrective action.

The instructions on the RTL indicated that the

refrigerator needs to be between 36-46 degrees

F.

The surveyor interviewed the LPN UM who stated

that the staff should have notified maintenance

right away when the temperature read 48 degrees

F on 06/03/19. The LPN UM said she was not

aware of this and stated she did not know why the

staff did not inform herself or maintenance of the

issue.

2. In the medication refrigerator the surveyor

observed an opened and undated

solution.

#1 How the corrective action will be

accomplished for those residents found to

have been affected.

The medications in the refrigerator were

transferred to another refrigerator and the

medication refrigerator was removed by

maintenance for 72 hours and placed

back into service as there no abnormal

temperatures observed.

The vial not dated was removed and

disposed of immediately. The

that was recently delivered to the facility

was discarded as it did not have the date

opened. The and

while not required to be dated

(manufacture expiration date) was

discarded as well.

#2 How the facility will identify other

residents having the potential to be

affected by the same deficient practice.

Medication carts and rooms were

checked and no other residents were

affected.

#3 What measures will be put in place or

systematic changes will be made to

ensure that the deficient practice will not

recur

Daily checks of Medication refrigerators

temps will be documented on the log

sheet and temperatures out of range will

be immediately reported to Supervisor

FORM CMS-2567(02-99) Previous Versions Obsolete TIYL11Event ID: Facility ID: NJ61315 If continuation sheet Page 2 of 4

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 06/07/2019 STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 761 Continued From page 2 F 761

The surveyor interviewed the LPN UM who stated

that the vial should have been dated when

opened. She further stated that the vial will be

removed from use and destroyed.

3. On 06/14/19 at 11:25 a.m., the surveyor

inspected the med cart #1,

in the presence of the Registered Nurse (RN), the

surveyor observed the following:

One box of , a

liquid medication used as and

, was opened

and not dated and one box of , an

used to was opened and

not dated.

The surveyor interviewed and asked the RN, what

is the facility policy for storing and dating

medication. The nurse stated, "I know the

medications should have been dated, but I don't

know the policy, I am just a per-diem nurse, I

don't work everyday, but I dated the medications

that I opened this morning".

On 06/05/19 at 1:10 p.m., the survey team met

with the Administrator and the DON and

discussed the above observations and concerns.

The DON stated that nurses are required to date

any medication that is opened.

A review of the Facility's Policy titled Medication

Storage revealed the following under procedure:

#3 "Medications will be stored at the appropriate

temperature in accordance with the pharmacy

and/or manufacturer labeling." #8 "Medications

requiring refrigeration will be stored in a

refrigerator that is maintained between 2 to 8

and designee (e.g. Maintenance) for

evaluation of medication and appliance.

Education to nursing staff was provided to

include the above assessment and action.

Education of Clinical Staff on proper

Medication Storage and dating was also

conducted.

#4

How the facility will monitor its corrective

actions to ensure that deficient practice is

being corrected and will not recur, i.e.

what QA program will be put into place to

monitor the continued effectiveness of the

systemic change.

Unit Managers (or designee) will conduct

random audits of two medication

refrigerators to monitor the proper

temperature and if action was

needed(e.g.temp high or low, it was

communicated. In addition, audits will

include four medication carts per week to

evaluate for proper dating. Audits will

continue for period of 4 weeks.

The results of these audits will be

submitted to Quality Assurance and

Performance Improvement

(QAPI)Committee for review for two

months to determine further action to plan

if needed

FORM CMS-2567(02-99) Previous Versions Obsolete TIYL11Event ID: Facility ID: NJ61315 If continuation sheet Page 3 of 4

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 06/07/2019 STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 761 Continued From page 3 F 761

degrees Celsius (36 to 46 degrees F)." #9

"Refrigerators used for medications storage will

contain a thermometer to indicate the

temperature within." #10 Temperature will be

checked daily to ensure it is within the specified

range. If temperature is out of range, the

refrigerator thermostat will be adjusted."

A review of the Facility's Policy titled Labeling of

Medication Containers revealed the following

under #3 "Labels for individual resident

medications include all necessary information,

such as: "h. The expiration date when applicable."

A review of the Facility Policy titled Labeling of

Medication Containers #3 "Labels for individual

resident medications did not include the dating of

individualized medication upon opening the

medication.

NJAC: 8:39-29.4 (a)(h)(d)

FORM CMS-2567(02-99) Previous Versions Obsolete TIYL11Event ID: Facility ID: NJ61315 If continuation sheet Page 4 of 4

A. BUILDING 01

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 06/07/2019 STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

E 000 Initial Comments E 000

This facility is in substantial compliance with

Appendix Z-Emergency Preparedness for All

Provider and Supplier Types Interpretive

Guidance 483.73, Requirements for Long Term

Care (LTC) Facilities.

K 000 INITIAL COMMENTS K 000

LIFE SAFETY CODE 101:2012

THIS FACILITY IS NOT IN SUBSTANTIAL

COMPLIANCE WITH THE MINIMUM LIFE

SAFETY CODE REQUIREMENTS AS

SURVEYED UNDER CMS-2786R.

K 321

SS=D

Hazardous Areas - Enclosure

CFR(s): NFPA 101

Hazardous Areas - Enclosure

Hazardous areas are protected by a fire barrier

having 1-hour fire resistance rating (with 3/4 hour

fire rated doors) or an automatic fire extinguishing

system in accordance with 8.7.1 or 19.3.5.9.

When the approved automatic fire extinguishing

system option is used, the areas shall be

separated from other spaces by smoke resisting

partitions and doors in accordance with 8.4.

Doors shall be self-closing or automatic-closing

and permitted to have nonrated or field-applied

protective plates that do not exceed 48 inches

from the bottom of the door.

Describe the floor and zone locations of

hazardous areas that are deficient in REMARKS.

19.3.2.1, 19.3.5.9

Area Automatic Sprinkler

Separation N/A

a. Boiler and Fuel-Fired Heater Rooms

K 321 6/21/19

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

06/21/2019Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete TIYL21Event ID: Facility ID: NJ61315 If continuation sheet Page 1 of 3

A. BUILDING 01

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 06/07/2019 STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

K 321 Continued From page 1 K 321

b. Laundries (larger than 100 square feet)

c. Repair, Maintenance, and Paint Shops

d. Soiled Linen Rooms (exceeding 64 gallons)

e. Trash Collection Rooms

(exceeding 64 gallons)

f. Combustible Storage Rooms/Spaces

(over 50 square feet)

g. Laboratories (if classified as Severe

Hazard - see K322)

This REQUIREMENT is not met as evidenced

by:

Based on observation and interview on 6/4/19, it

was determined that the facility failed to ensure

that rooms over 50 square feet, and that are used

to store combustible supplies had doors that were

capable to automatically close.

This deficient practice was evidenced by the

following:

During a tour of the building with the facility's

Maintenance Director and Regional Plant

Operations Director, the surveyor observed the

Medical office at station 3 had over 20 large filled

combustible cardboard boxes, a large volume of

paper files were being stored in an open area of

the office. The surveyor noted that the room

measured is greater than 50 square feet and the

door was not equipped with a self-closure to force

the door to automatically close upon being

opened.

On 6/4/19 at 11:55 a.m., an interview was

conducted with the facility's Maintenance Director

and the Regional Plant Operations Director who

stated and acknowledged that the Medical

Records office that is greater that 50 square feet,

should have an auto closing device installed on

the door to force the door to automatically close.

#1- The automatic closing device was

immediately installed to door in question

#2- All residents have the potential to be

affected by deficient practice. This plan off

correction applies to all future and current

residents

#3- To ensure the deficient practice does

not recur, the facility will conduct weekly

Maintenance rounds and check all

storage areas over 50 sq. ft. and use

combustible supplies have automatic door

closures. Weekly checks will be logged on

Maintenance log sheets. Additionally staff

were in-services

#4 To monitor corrective action, the

weekly maintenance logs will be review by

Maintenance Director for 4 weeks.

#5 The results of weekly audits will be

presented to centers QAPI team at

quarterly meeting

FORM CMS-2567(02-99) Previous Versions Obsolete TIYL21Event ID: Facility ID: NJ61315 If continuation sheet Page 2 of 3

A. BUILDING 01

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 06/07/2019 STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

K 321 Continued From page 2 K 321

NJAC 8:39-31.2(e)

FORM CMS-2567(02-99) Previous Versions Obsolete TIYL21Event ID: Facility ID: NJ61315 If continuation sheet Page 3 of 3

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 07/17/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315087 08/08/2018

C

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1040 ROUTE 36 CARE ONE AT KING JAMES

ATLANTIC HIGHLANDS, NJ 07716

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

COMPLAINT: NJ11311

CENSUS: 89

SAMPLE SIZE: 4

T HE FACILITY IS IN COMPLIANCE WITH THE

REQUIREMENTS OF 42 CFR PART 483,

SUBPART B, FOR LONG TERM CARE

FACILITIES BASED ON THIS COMPLAINT

VISIT.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

08/28/2018Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete 3OZ711Event ID: Facility ID: NJ61315 If continuation sheet Page 1 of 1