Christ the King Manor

In the surveyor’s words

From the most serious findings on record at Christ the King Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF760Jun 4, 2026

  Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of 35 residents reviewed (Resident 93).Findings include:A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 93, dated June 2, 2026, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner), and had diagnoses that included cerebral infarction (a loss of blood flow to the brain causing physical deficits). […]

• No harm, potential for more than minimal, patternF641Jun 13, 2024

  Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 42 residents reviewed (Residents 17, 52, 63, 64, 98, 103, 117). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section O0110G1b (non-invasive mechanical ventilator) and Section O0110G3b (CPAP- Continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while sleeping) was to be checked if a CPAP… […]

• No harm, potential for more than minimal, patternF693Jun 13, 2024

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an enteral feeding was administered in accordance with physician's orders for one of 42 residents reviewed (Resident 67). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated April 25, 2024, revealed that the resident was understood, could understand others, and had a feeding tube. […]

• No harm, potential for more than minimal, patternF842Jun 13, 2024

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for two of 42 residents reviewed (Residents 24, 67). Findings include: A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated April 20, 2024, revealed that the resident was usually understood, could usually understand others, and had a diagnosis of dementia. […]

• No harm, potential for more than minimal, patternF684Jul 20, 2023

  Based on a review of the facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor a resident's blood pressure as ordered prior to medication administration for one of 48 residents reviewed (Resident 115). Findings include: The facility's policy for administration of medication, dated July 23, 2023, indicated that medication that requires blood pressure parameters is to be obtained and charted on the medication administration record. A diagnosis record for Resident 115, dated April 17, 2023, included diagnoses of atrial fibrillation (irregular heart rhythm) and heart failure. […]