Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Village Care Of King during CMS and state inspections, most recent first.
The facility did not maintain documented evidence of an active QAPI program for all residents during the review period. Although a written QAPI plan described data-driven decision-making, goal setting, and use of quality data, monthly QAPI committee records contained only staff signatures without any documented discussion topics, identified concerns, data tracking, or Performance Improvement Plans (PIPs). The Administrator reported that QAPI meetings occurred monthly and concerns were discussed verbally using a computer-based system, but was unable to produce any records showing identified issues, goals, or ongoing PIPs, and acknowledged that no formal PIPs were in place during the period reviewed.
A resident admitted with major depression, PTSD, anxiety, and insomnia, and documented on the admission MDS as having a serious mental illness while receiving antidepressant medications, did not receive a required Level II PASRR evaluation. The resident had an existing Level I PASRR from a prior setting, but facility records contained no evidence that a Level II evaluation was requested. The SW acknowledged not submitting the request, stating the resident was inadvertently missed in the usual morning-meeting process used to identify new admissions needing PASRR screening, and the Administrator reported being unsure whether Level II PASRR requests had been submitted for this or any resident, despite expecting the SW to do so for residents with serious mental health diagnoses.
The facility failed to develop comprehensive, measurable care plans for two residents with identified behavioral, PTSD, and hospice needs. One resident with major depression, PTSD, anxiety, and insomnia had documented verbal abuse toward staff and refusals of care in nursing notes, yet the care plan addressed only depression, antidepressant use, and rejection of care, omitting specific interventions for verbal behaviors and PTSD. Another resident receiving hospice services after readmission had hospice confirmed on the MDS, but the care plan contained no focus, goals, or interventions related to hospice care. Staff interviews revealed confusion over responsibility for care plan development, with the MDS nurse, social worker, and DON each indicating that any nurse could update care plans and that no single person was designated to create them.
A resident in a LTC facility suffered a severe leg fracture after being manually lifted from a shower chair to a bed by a nursing assistant, despite requiring maximum assistance with a sliding board or mechanical lift. The resident's care plan was missing, and staff inconsistencies in transfer practices contributed to the incident.
A resident experienced severe pain and swelling in her right leg after being manually lifted from a shower chair to a bed, resulting in her leg getting caught and causing a fracture. Despite the resident's complaints to multiple nurses, none notified the physician or conducted a thorough assessment until two days later, when an x-ray revealed the fracture. The facility failed to notify the physician of the resident's change in condition in a timely manner.
A resident in a LTC facility experienced a delay in medical treatment after reporting severe leg pain following a manual transfer by a nursing assistant. Despite multiple complaints, several nurses failed to conduct comprehensive assessments or document the resident's condition over two days. It was only after a thorough assessment by a nurse on the third day that a fracture was discovered, leading to appropriate medical intervention.
Lack of Documented QAPI Activities and Performance Improvement Plans
Penalty
Summary
The facility failed to maintain and produce documented evidence of a comprehensive and ongoing Quality Assurance and Performance Improvement (QAPI) program for calendar year 2025, affecting all 94 residents. Review of the facility’s written QAPI plan showed it described principles such as making resident care decisions based on data, setting performance goals, measuring progress toward those goals, and using collected quality improvement data to guide daily operations. However, when surveyors reviewed the QAPI committee meeting minutes from January through December 2025, the documents only contained signatures of interdisciplinary staff in attendance each month and lacked any documentation of topics discussed, identified concerns, data tracking, or measures taken or planned to address concerns in the form of Performance Improvement Plans (PIPs). During an interview, the Administrator stated that the QAPI committee met monthly and that meetings were conducted in person while using a computer-based documenting system, but formal meeting minutes were not taken and concerns were discussed verbally. The Administrator was unable to provide any documentation from the computer-based system or other sources showing identified concerns, data tracking, goals, or ongoing PIPs for 2025. The Administrator further acknowledged that there were no formal ongoing PIPs in place during the previous calendar year or at the time of the interview, despite the facility’s written QAPI policy outlining the expectation for systematic identification, reporting, investigation, analysis, and prevention of adverse events and the development, implementation, and evaluation of corrective actions.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with serious mental illness. Documentation showed the resident had a Level I PASRR determination dated 10/24/22 with no expiration date and was admitted in April 2025 with diagnoses including major depression, post-traumatic stress disorder (PTSD), and anxiety. The admission MDS assessment documented that the resident had a serious mental illness and/or intellectual disability and was receiving antidepressant medications, with pertinent diagnoses of major depression, insomnia, anxiety, and PTSD. A psychiatric progress note dated 9/29/25 further confirmed ongoing treatment for major depressive disorder, PTSD, and insomnia with duloxetine and trazodone. Record review revealed no evidence that a Level II PASRR evaluation had ever been requested or completed for this resident. The facility was unable to provide documentation that a request for a Level II PASRR evaluation had been submitted. In an interview, the Social Worker stated the resident was admitted with a Level I PASRR and acknowledged she had not submitted a Level II request, explaining that she typically identified new admissions needing PASRR screening through morning meetings and must have inadvertently missed this resident. In a separate interview, the Administrator reported uncertainty about whether Level II PASRR requests had been submitted for this or any resident and stated an expectation that the Social Worker would request a new Level II PASRR evaluation for residents admitted with serious mental health diagnoses, even if they had a prior Level I from another facility.
Failure to Develop Comprehensive Care Plans for Behavioral, PTSD, and Hospice Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for two residents. For one resident admitted with major depression, post-traumatic stress disorder (PTSD), and anxiety, the admission MDS documented these diagnoses and the use of two antidepressants, and a later psychiatric note confirmed major depressive disorder, PTSD, and insomnia with ongoing antidepressant therapy. Nursing progress notes from September 2025 onward documented verbal abuse toward staff and refusals of weights and blood draws. The resident’s comprehensive care plan, initiated in April 2025 and last revised in December 2025, included depression, antidepressant use, and rejection of care, but did not include any focus, goals, or interventions related to the resident’s verbal behaviors or PTSD diagnosis. Staff interviews showed that nurse aides recognized the resident as alert, oriented, and sometimes challenging due to refusals of care, and described strategies such as using two aides and leaving the room to allow the resident to calm down before reattempting care. The MDS nurse reported that the resident was not coded for behaviors on any MDS assessments because the behaviors did not occur daily during the look-back periods and believed the social worker handled mental illness and behavior care plans, while the social worker stated she did not complete any portions of care plans and that nursing staff were responsible. The DON acknowledged awareness of the resident’s behaviors and that the resident should have been care planned for verbal behaviors and PTSD, and also stated there was no single person responsible for creating care plans, with any nurse able to update them. In a second case, another resident was readmitted with hospice services following hospitalization, and hospice services began in November 2025, with a significant change MDS confirming hospice. However, the resident’s care plan, last revised in September 2025, lacked any focus area, goals, or interventions for hospice care. The MDS nurse and DON both indicated that hospice services should have been included in the care plan and described that there was no designated individual responsible for care plans, with any nurse able to update them.
Inadequate Supervision and Unsafe Transfer Practices Lead to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and safe care for a resident, leading to an accident that resulted in a severe injury. The resident, who was cognitively intact and dependent on assistance for transfers due to impaired functional limitations, was manually lifted by a nursing assistant from a shower chair to a bed. This action caused the resident's right leg to hit the shower chair and become caught, resulting in severe pain and swelling. An x-ray confirmed an acute distal tibia/fibula fracture. The resident's care plan, which was missing at the time of the incident, indicated that she required maximum assistance with transfers using a sliding board or mechanical lift due to her inability to bear weight. Despite this, the nursing assistant manually lifted the resident without the use of a mechanical lift or additional staff assistance, contrary to the recommended transfer methods. The resident reported severe pain during the transfer, but the nursing assistant continued the transfer without seeking immediate medical assessment. Interviews with staff revealed inconsistencies in the understanding and implementation of the resident's care plan. The nursing assistant involved in the incident claimed that the care plan did not specify the use of a mechanical lift, and that manual lifting was a common practice among staff. The facility's failure to ensure the availability and adherence to an accurate care plan, along with the lack of proper supervision and training for staff, contributed to the resident's injury.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who experienced severe pain and swelling in her right leg after being manually lifted from a shower chair to a bed by a nursing assistant. The incident occurred when the resident's leg got caught between the shower chair and the bed, causing significant pain. Despite the resident's complaints of pain to multiple nurses over the following days, none of the nurses notified the physician or conducted a thorough assessment until two days later when a nurse finally assessed the resident and notified the provider. The resident, who was cognitively intact, reported the incident and her pain to the nursing assistant immediately after the transfer. However, the nursing assistant did not inform the nurse about the specifics of the transfer or the resident's pain. Subsequent nurses who were informed of the resident's pain either did not assess the resident or did not notify the physician, believing there was no need for further action. It was not until a nurse on the third day assessed the resident's leg, found it swollen and discolored, and notified the provider, that an x-ray was ordered, revealing a fracture. The medical director and regional nurse consultant confirmed that the physician was not notified of the resident's complaints of pain until two days after the incident. The facility's administrator stated that all residents should have their needs met and that the physician should be notified of any change in condition. The failure to notify the physician in a timely manner resulted in a delay in diagnosing and treating the resident's fracture.
Failure to Assess Resident's Injury Leads to Delayed Treatment
Penalty
Summary
The facility failed to complete and document ongoing comprehensive assessments for a resident who reported leg pain, which delayed medical treatment and interventions. On October 22, 2024, a resident was manually lifted by a nursing assistant from a shower chair to a bed, causing the resident's right leg to hit the chair and get caught between the chair and the bed, resulting in pain and swelling. Despite the resident's complaints of severe pain, multiple nurses failed to conduct a comprehensive assessment of the resident's condition over the following days. The resident, who was cognitively intact and had a history of conditions including right hand contracture and spinal issues, reported the incident and pain to several staff members. However, the nurses on duty did not perform thorough assessments or document the resident's condition adequately. Nurse #1, who was informed of the pain, did not assess the resident, and Nurse #2, who was aware of the incident, did not report it to the administration or document an assessment. Nurses #3 and #4 also failed to document any assessments despite being notified of the resident's pain. It was not until October 24, 2024, that Nurse #5 assessed the resident and noted swelling and discoloration of the leg, leading to a physician being notified and an x-ray being ordered. The x-ray revealed a fracture, and the resident received new orders for additional pain medication. The facility's Regional Nurse Consultant and Medical Director confirmed that the resident was not assessed on the days following the incident, and the deficiency in care was acknowledged by the facility's administration.
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Illustrative
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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Nursing homes near King
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| King Health And Rehabilitation Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Oak Forest Health And Rehabilitation | 7.9 mi | ★★★★★ | 0 | 0 |
| Salemtowne | 8.6 mi | ★★★★★ | 2 | 0 |
| Mill Creek Center For Nursing And Rehabilitation | 8.6 mi | ★★★★★ | 1 | 0 |
| Brookridge Retirement Community | 9.8 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.