Below 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 Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure the steam table shelf in the kitchen was cleaned according to policy, as it was observed with dried food debris and a sticky surface on multiple occasions. Staff confirmed the shelf should have been cleaned but was not.
A resident with newly identified serious mental illnesses, including bipolar disorder and major depressive and generalized anxiety disorders, was not referred for a required Level II PASRR. The Social Worker responsible for PASRR referrals was not notified of the new diagnoses, and the medical record system failed to generate an alert, resulting in the deficiency.
The facility did not maintain accurate and updated care plans for three residents with complex medical needs, including one with a urinary catheter, one receiving dialysis, and one on tube feeding. Care plans were not revised to reflect changes in clinical status, such as the presence of a catheter, updated dialysis schedules, or a new NPO diet order, due to lapses in communication and assessment by nursing and MDS staff.
A nurse failed to label a newly hung tube feeding formula bottle for a resident who was dependent on enteral nutrition due to multiple medical conditions. The bottle was observed without required information such as the resident's name, date, time, or flow rate. Facility leadership and the nurse confirmed that labeling was required by policy, but the omission occurred without explanation.
A nurse administered a controlled medication to a resident for pain but did not immediately document the administration on the controlled medication count sheet as required by facility policy. The nurse later acknowledged the omission, and the DON confirmed that the correct procedure was not followed.
Expired medications, including Bisacodyl Suppositories, CoQ10, and Antacid Antigas liquid, were found on two medication carts. Staff interviews revealed confusion and missed checks regarding responsibility for removing expired drugs, with both medication aides and nurses indicating uncertainty or oversight in the process.
A resident was readmitted with an indwelling urinary catheter due to obstructive and reflux uropathy, but the facility failed to obtain physician orders for catheter care and management for several months. Although the care plan included interventions for catheter care, staff provided care based on routine practice without required physician orders, and the absence of orders was not identified or reported by nursing staff or supervisors.
Failure to Maintain Sanitary Conditions of Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, specifically by not cleaning under the shelf of the steam table. During observations, the 5-foot steam table shelf was found to have dark brown dried food debris and was sticky to the touch on two separate occasions. Review of the facility's Food Service Closing Checklist indicated that steam tables should be cleaned and turned off, but this was not followed. Staff interviews confirmed that the steam table shelf should have been cleaned, but it was not done as required.
Failure to Refer Resident for Level II PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) after new diagnoses of serious mental illnesses were identified. The resident was initially admitted with a Level I PASRR determination that did not require further screening unless a significant change in mental health status occurred. Subsequent medical record reviews showed that the resident was diagnosed with bipolar disorder and later with major depressive and generalized anxiety disorders. Despite these new diagnoses, there was no evidence that a Level II PASRR referral was completed as required. Interviews with facility staff revealed gaps in communication and notification processes. The Social Worker, responsible for completing Level II PASRR screenings, was unaware of the new mental health diagnoses and stated she typically relied on notifications from the MDS nurse or DON. The DON indicated that the medical record system was supposed to alert the Social Worker to new mental health diagnoses but was unsure why this did not occur in this case. The Administrator was also unaware that the required referral had not been completed.
Failure to Maintain Comprehensive and Updated Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and maintain comprehensive care plans for multiple residents with significant clinical needs. For one resident with obstructive and reflux uropathy, the care plan for an indwelling urinary catheter was created upon readmission but was resolved prematurely without proper reassessment or verification of the catheter's presence. Despite documentation and clinical notes indicating the continued use of the catheter, the care plan was not updated until after a subsequent hospitalization, indicating a lapse in ongoing assessment and care planning. Another resident with end stage renal disease and dependence on hemodialysis experienced a change in dialysis schedule as ordered by the physician. However, the care plan was not updated to reflect the new dialysis days, as the change was not communicated effectively during clinical meetings and was not incorporated into the care plan by the responsible staff. This resulted in the care plan containing outdated information regarding the resident's dialysis schedule. A third resident with oropharyngeal dysphagia and severe cognitive impairment had a change in dietary status to nothing by mouth (NPO) as per physician order. The care plan, however, continued to indicate that the resident received a meal tray and was not updated to reflect the NPO status. Staff interviews confirmed that changes in care were communicated during clinical meetings, but the care plan was not revised accordingly, leading to discrepancies between the resident's current orders and the documented care plan.
Failure to Label Tube Feeding Formula Bottle
Penalty
Summary
A deficiency occurred when a nurse failed to label a newly hung tube feeding formula bottle for a resident who was dependent on enteral nutrition due to diagnoses including failure to thrive, dysphagia, and gastrostomy status. The resident was cognitively intact and required staff assistance for most activities of daily living, receiving all nutrition and hydration through a feeding tube. According to the care plan and physician orders, tube feedings were to be administered per specific instructions, including documentation and labeling requirements. On observation, the tube feeding formula bottle in the resident's room was found without a label indicating the resident's name, date, time, or flow rate. Interviews with the ADON, DON, and the nurse responsible confirmed that facility policy required labeling of tube feeding bottles with this information when hung. The nurse acknowledged the omission but could not provide a reason for failing to label the bottle as required.
Failure to Document Controlled Substance Administration per Policy
Penalty
Summary
A staff member failed to follow facility policy regarding the documentation of controlled substances during medication administration. Specifically, Nurse #1 administered a controlled medication, Oxycodone 10mg, to a resident for pain management but did not immediately document the administration on the controlled medication count sheet as required by facility policy. The policy mandates that the licensed nurse must immediately record the date and time of administration, amount administered, remaining quantity, and their initials on the accountability record and medication administration record after giving the medication. This deficiency was identified during an observation of a medication pass, where Nurse #1 was seen administering the medication but not signing it out on the count sheet. In subsequent interviews, Nurse #1 acknowledged the omission and confirmed awareness of the correct procedure. The DON also confirmed that the expected process was not followed in this instance.
Expired Medications Not Removed from Medication Carts
Penalty
Summary
Surveyors observed that expired medications were not discarded from two of three medication carts reviewed. On the D Hall medication cart, an opened box of Bisacodyl Suppositories with an expiration date of 3/31/25 was found. On the E Hall medication cart, an opened bottle of CoQ10 and an opened bottle of Antacid Antigas liquid, both with expiration dates of 2/2025, were present. Medication Aide #1 indicated she believed nurses were responsible for checking for expired medications, while Nurse #2 stated that the nurse assigned to the cart was responsible but admitted to missing the expired medications during her check. The Assistant Director of Nursing confirmed that both assigned nurses and management team nurses, as well as the consulting pharmacist, are responsible for checking medication carts for expired drugs.
Failure to Obtain Physician Orders for Indwelling Urinary Catheter Management
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician orders for the management of an indwelling urinary catheter for a resident who was readmitted with obstructive and reflux uropathy. The resident was readmitted with an indwelling urinary catheter, as documented in the nursing admission tool and provider progress notes. Despite this, a review of the electronic medical record revealed that no physician orders regarding the care or management of the indwelling urinary catheter were entered from the time of readmission until several months later. The care plan created upon readmission included interventions for catheter care, such as maintaining the catheter anchor, observing for signs of infection, and providing catheter care each shift. However, these interventions were not supported by corresponding physician orders in the resident's record. Staff interviews confirmed that catheter care was provided as part of routine practice, but also revealed that staff were unaware of the absence of required physician orders and did not notify supervisors about the missing orders. The Director of Nursing confirmed that no catheter care or changing orders were found for the resident prior to the later date, and the Administrator acknowledged that nursing staff did not follow up on the missing orders from the hospital discharge summary. The deficiency was attributed to the failure of the admitting nurse to enter the necessary orders and the assumption by staff that catheter care would be completed regardless of the presence of orders.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near King
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Care Of King | 1.2 mi | ★★★★★ | 3 | 0 |
| Oak Forest Health And Rehabilitation | 8.7 mi | ★★★★★ | 0 | 0 |
| Mill Creek Center For Nursing And Rehabilitation | 9.7 mi | ★★★★★ | 1 | 0 |
| Salemtowne | 9.7 mi | ★★★★★ | 2 | 0 |
| Brookridge Retirement Community | 10.8 mi | ★★★★★ | 1 | 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.