King Manor Care and Rehabilitation Center violated federal notification requirements during a February incident involving a resident with severely impaired cognition, according to an October inspection report from federal regulators.
The resident, identified only as Resident #1 in the complaint investigation, had been admitted with multiple serious conditions including urinary tract infection, congestive heart failure, and chronic respiratory failure with inadequate oxygen supply to body tissues.
A January assessment showed the resident scored just 3 out of 15 on a standard cognitive test, indicating severely impaired mental status. Such residents cannot advocate for themselves when medical problems arise.
On February 24, during the overnight shift from 11 p.m. to 7 a.m., staff recorded the resident's temperature as 100.2°F on the medication administration record. But inspectors found no nursing notes about the fever anywhere in the resident's chart.
Nobody took follow-up temperatures during that shift to monitor whether the fever was rising or falling. The facility's own records show no evidence that staff called the resident's physician or notified family members about the change in condition.
Federal regulations require nursing homes to immediately inform residents, their doctors, and family members of situations that affect the resident's health. Fever can signal serious infections that require prompt medical attention, particularly in elderly patients with multiple chronic conditions.
When questioned by inspectors in October, Registered Nurse #1 described proper fever protocols: administer Tylenol, take temperatures every four hours to determine if additional medication is needed, document any change in condition, and call both the physician and family.
"The staff documents for any change in condition and call the physician and family," the nurse told inspectors during an October 27 interview.
The Director of Nursing provided similar guidance about fever response during her interview the same day. She told inspectors that staff should document all actions taken, continue monitoring the patient, offer fluids, call the physician if laboratory work is needed, notify the family, administer Tylenol, and document everything.
"If a resident has fever, the staff should be documenting all they do so they would know what to follow through," the nursing director said.
The facility's own policies, dated January 2025, require nurses to notify the attending physician or on-call doctor when there has been a "significant change in the resident's physical, emotional, or mental condition." The same policy mandates notifying the resident's representative when there is "a significant change in the resident's physical, mental, or psychosocial status."
A separate facility policy from December 2024 states that "all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record."
Despite these clear written protocols and staff knowledge of proper procedures, the facility failed to follow either requirement in this case.
The inspection was conducted in response to a complaint filed against the facility. Inspectors reviewed medical records and interviewed staff members to investigate the allegation.
King Manor Care operates at 2303 West Bangs Avenue in Neptune. The facility treats residents with complex medical conditions including those requiring rehabilitation services.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. However, the failure to notify medical professionals and family members of fever in a cognitively impaired resident represents a breakdown in basic safety protocols designed to protect vulnerable patients.
For residents with severe cognitive impairment, family members and medical providers serve as essential advocates who can recognize when symptoms require immediate attention. When nursing homes fail to communicate changes in condition, residents lose this critical safety net.
The resident's multiple chronic conditions, including heart failure and respiratory problems, would make fever particularly concerning as it could indicate a serious infection requiring prompt medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for King Manor Care and Rehabilitation Center from 2025-10-27 including all violations, facility responses, and corrective action plans.
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