Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Christ The King Manor during CMS and state inspections, most recent first.
Failure to follow warfarin orders led to significant med errors for a cognitively intact resident with a mechanical heart valve and hx of cerebral infarction. MAR review showed missed doses in one month and incorrect dosing and omissions in another, and the DON confirmed the orders were not followed.
The facility failed to review and revise care plans for two residents when their documented needs changed. One resident had cognitive impairment, a hiatal hernia with food impaction, and a full liquid diet order, but the care plan did not accurately reflect the resident’s active care needs. Another resident had cognitive impairment and made self-harm statements, yet the care plan was not updated to address those statements or identify staff interventions; the DON confirmed the care plan should have been updated.
A resident with moderate cognitive impairment and a diagnosis of diaphragmatic hernia with obstruction had orders for lorazepam 0.5 mg, including one-half tablet at bedtime and PRN dosing for anxiety/restlessness. Review of the MAR and controlled drug record showed that a full tablet was signed out on multiple occasions when only one-half tablet was ordered, with no documented evidence that the remaining half was administered and wasted; the DON confirmed the discrepancy.
A resident with severe cognitive impairment, CHF, anemia, and behavioral issues had physician orders and care plans requiring scheduled bumetanide, risperidone, and acetaminophen. Review of the MAR showed that one afternoon, the resident did not receive the ordered doses of all three medications, and the omission was confirmed by the NHA and DON, demonstrating a failure to administer medications as ordered and in a timely manner.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in documenting care needs and treatments. Errors included unrecorded use of CPAP devices, medications, dialysis treatments, and incorrect documentation of falls and discharge destinations. These inaccuracies were confirmed through interviews with the DON.
A resident with a feeding tube received enteral feeding contrary to physician's orders, which specified administration only if meal consumption was below a certain threshold. Despite consuming adequate meal points, the resident was given supplemental Glucerna 1.5 Cal, as confirmed by the DON.
The facility failed to maintain accurate clinical records for two residents. One resident's records showed administration of Roxanol without corresponding wound care, while another resident's records indicated PEG-tube flushes without actual feeding. These discrepancies were confirmed by the DON.
Failure to Follow Warfarin Orders
Penalty
Summary
The facility failed to ensure that physician orders were followed for Resident 93, resulting in significant medication errors involving warfarin. Resident 93 was cognitively intact, received an anticoagulant, and had diagnoses including cerebral infarction and a mechanical heart valve requiring lifelong blood-thinning medication. A review of the resident’s MAR showed that warfarin ordered in December 2025 was not administered from December 18 through December 21, 2025. In addition, physician orders in May 2026 directed specific warfarin doses on alternating days, but the MAR showed that staff administered 7.5 mg on May 12 and May 14, and no warfarin was given on May 13 or May 15. The DON confirmed that a medication error occurred in December and that the warfarin orders were not followed in May 2026.
Failure to Update Care Plans for Changed Resident Needs
Penalty
Summary
The facility failed to review and revise care plans for two residents whose documented needs had changed. One resident had an admission MDS showing moderate cognitive impairment, required staff assistance with daily care, and had diagnoses including diaphragmatic hernia with obstruction. Physician orders included a full liquid diet with thin liquids, and the resident’s care plans referenced anemia, a large hiatal hernia with food impaction, and later the potential for altered nutrient utilization with instructions to provide a full liquid diet. The Nursing Home Administrator confirmed that the care plan did not accurately reflect the resident’s active care needs and should have been revised. A second resident had a quarterly MDS showing cognitive impairment and need for staff assistance with daily care. The resident’s care plan identified behaviors, and a nursing note documented that the resident stated he wanted to harm himself. A nurse aide reported that the resident makes self-harm threats when frustrated and has made similar statements before. There was no documented evidence that the care plan was updated to reflect the self-harm statements or to identify interventions for staff to use when those statements occurred, and the DON confirmed that the care plan should have been updated.
Failure to Follow Lorazepam Orders and Document Partial Dose Waste
Penalty
Summary
The facility failed to follow physician’s orders for one resident with moderate cognitive impairment who required staff assistance with daily care and had a diagnosis of diaphragmatic hernia with obstruction. The resident had orders for lorazepam 0.5 mg by mouth in the morning and one-half tablet at bedtime for anxiety, along with an additional order for one-half tablet as needed for anxiety/restlessness for 14 days. Review of the controlled drug record and MAR showed that on multiple occasions a full 0.5 mg tablet of lorazepam was signed out for administration when the order called for one-half tablet to be given. On the documented dates and times, there was no evidence that one-half of the tablet was administered and the remaining one-half was wasted. The DON confirmed that the full tablet was signed out when only one-half tablet was ordered and that there was no documented evidence of administration and waste of the unused portion.
Failure to Administer Ordered Medications as Scheduled
Penalty
Summary
The deficiency involves a failure to ensure timely medication administration according to physician orders and the resident’s care plans. Facility policy dated January 4, 2026, required that all medications be administered safely and appropriately. Resident 2 had an MDS assessment indicating severe cognitive impairment, dependence on staff for daily care, need for two-person assistance with transfers, and wheelchair use. The resident had care plans for anemia, congestive heart failure requiring bumetanide, and behavior management requiring administration of medications as ordered. Physician orders directed that the resident receive 1 mg of bumetanide by mouth twice daily, 1 mg of risperidone (one-half tablet) by mouth once daily, and two 325 mg tablets of acetaminophen by mouth three times daily for pain. Review of the resident’s February 2026 medication administration record showed that on February 1, 2026, the scheduled 2:00 p.m. doses of bumetanide, risperidone, and acetaminophen were not administered. There was no documentation of adverse effects related to the missed doses. The physician was notified the following day, and no new orders were given. In an interview, the Nursing Home Administrator and Director of Nursing confirmed that the medications were not administered but should have been, establishing that the facility did not follow its own policy or the physician’s orders for medication administration for this resident.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, leading to discrepancies in the documentation of their care needs and treatments. For Resident 17, the MDS did not reflect the use of a CPAP device with oxygen, despite physician orders and medication administration records (MAR) indicating its nightly use. Similarly, Resident 52's MDS failed to document the administration of diuretic, antidepressant, and opioid medications, which were prescribed and recorded in the MAR. Resident 63's MDS did not indicate dialysis treatment, although physician orders required communication forms for dialysis sessions. Resident 64's MDS inaccurately reflected the use of a CPAP device and oxygen, contrary to physician orders and MAR records. Additionally, Resident 98's MDS incorrectly stated no falls had occurred, despite documentation of a fall resulting in a hip fracture. Resident 103's MDS inaccurately recorded a fall with a major injury, while the incident involved only a superficial scratch. Finally, Resident 117's discharge MDS incorrectly indicated a discharge to a short-term general hospital, whereas physician orders specified a discharge to home. These inaccuracies were confirmed through interviews with the Director of Nursing, highlighting a pattern of errors in the facility's MDS assessments, which are crucial for accurately reflecting residents' care needs and treatments.
Improper Administration of Enteral Feeding
Penalty
Summary
The facility failed to administer enteral feeding in accordance with the physician's orders for a resident who required supplemental tube feeding. The resident, who was understood and could understand others, had a feeding tube and was on a care plan that required 240 ml of Glucerna 1.5 Cal to be administered via PEG-tube after meals if the resident consumed less than three points of her meal. However, the resident's records indicated that she received the bolus feeding on several occasions when her meal points were three or above, contrary to the physician's orders. The Director of Nursing confirmed that the resident received the 240 ml bolus feeding of Glucerna 1.5 Cal on dates when her meal points were three and/or above, which should not have occurred. This discrepancy between the physician's orders and the actual administration of the feeding represents a failure in ensuring that the enteral feeding was administered correctly, as per the resident's care plan and physician's instructions.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents. For Resident 24, there was a significant change in status Minimum Data Set (MDS) assessment indicating the resident was usually understood and had a diagnosis of dementia. Physician's orders required specific wound care and administration of Roxanol prior to wound care. However, the Treatment Administration Record (TAR) showed that the night shift staff documented administering Roxanol without completing any wound care, as confirmed by the Director of Nursing. For Resident 67, the quarterly MDS assessment showed the resident had a feeding tube and required supplemental tube feedings. Physician's orders specified the administration of Glucerna via PEG-tube and flushing the tube with warm water before and after feedings. The Medication Administration Records (MARs) indicated multiple instances where the Glucerna was not administered, yet the TARs showed the PEG-tube was flushed as if the feeding had occurred. This discrepancy was confirmed by the Director of Nursing, indicating inaccurate documentation of the resident's care.
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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 Dubois
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dubois Nursing Home | 2.3 mi | ★★★★★ | 22 | 0 |
| Highland View Rehabilitation & Healthcare Center | 8.6 mi | ★★★★★ | 7 | 0 |
| Mulberry Healthcare And Rehabilitation Cent | 16.1 mi | ★★★★★ | 34 | 0 |
| Dr Arthur Clifton Mckinley Ctr | 16.3 mi | ★★★★★ | 4 | 0 |
| Ridgeview Healthcare And Rehabilitation Center | 16.4 mi | ★★★★★ | 21 | 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.