King David Center for Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the residents' right to a safe, clean, and comfortable homelike environment. Specifically, housekeeping and maintenance services were not maintained in Units 2, 3, 4, 5, and 8.

Inspectors wroteBased on observation, record review, and interviews, during the Recertification and Complaint (#523045) Survey, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 3 (Residents #63, 145, and 12) of 4 residents reviewed for Accidents out of 35 total sampled residents. Specifically, 1.) On 11/25/2024, Resident #63 had an unwitnessed incident when they were observed on the floor and complained of pain to the left hip. [...]

Inspectors wroteBased on interview and record review conducted during the Recertification Survey from 09/24/2025 to 10/01/2025, the facility did not ensure a comprehensive person-centered care plan was reviewed and revised to address a resident's needs. This was evident for 2 (Residents #164 and #116) of 38 total sampled residents. Specifically, 1) Resident #164's comprehensive care plan was not reviewed and revised to reflect Resident #164's behavior problem, and 2) Resident #116's comprehensive care plans were not reviewed and revised to reflect the elopement/wandering behavior.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety. This was evident during the kitchen observation task and dining observation for one (1) (Unit 8) of 7 units observed. Specifically, 1.) The kitchen staff's facial hair was not fully covered during food preparation, 2.) Enteral feedings were not discarded past it's used by date, and 3.) Certified Nursing Assistant #8 was handling residents' food with bare hands.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that all injuries of unknown origin were thoroughly investigated. This was evident for 1 (Resident #145) of 3 residents reviewed for Notification of Change out of 38 sampled residents. Specifically, on 04/06/2025, Resident #145 was observed with a laceration on the right side of their head. The facility initiated the investigation but failed to thoroughly investigate the incident to rule out abuse and/or neglect.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 of 8 residents reviewed for Accidents (Resident #116) and 1 out of 5 residents reviewed for Unnecessary Medications (Resident #164). Specifically, 1.) Resident # 116 had no comprehensive care plan developed to address ongoing disruptive behaviors. 2.) Resident #164 had no comprehensive care plan developed for anticoagulant therapy.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in one (1) of 1 resident observed for respiratory care. Specifically, on 09/25/2025, Enhanced Barrier Precautions were not maintained during tracheostomy suctioning.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification/Complaint survey conducted from 1/4/24 to 1/10/24, the facility did not ensure that the resident was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and resident's representatives were not consistently invited to participate in their care plan meetings. This was evident for 1 resident reviewed for care plans out of 38 residents. (Residents #112).

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification survey from 1/4/24 to 1/10/24, the facility did not ensure that the resident received services that accommodated the resident's needs and preferences. Specifically, the call bell in Resident #237's bathroom did not work.

Inspectors wroteBased on observations, interviews, and record reviews during a Recertification/Complaint survey from 1/4/23 to 1/10/23, the facility did not ensure that assessments accurately reflected the residents' status. Specifically, the admission assessment did not reflect the presence of a colostomy device that was used for a resident. This was evident for 1 of 1 resident reviewed for Urinary Catheter out of a sample of 38 residents. (Resident #24)

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification and Complaint Survey (NY00297824) from 01/03/2024 to 01/10/2024, the facility did not ensure that menus and dietary preferences were followed. This was evident for 2 (Resident #463 and Resident #125) of 4 residents reviewed for Food out of 38 total sampled residents. Specifically, 1). Resident #125 did not receive food items listed on their tray ticket during mealtime, and 2). Resident #463 did not receive a cheese sandwich as preferred.

Inspectors wroteBased on observation, record review and interview conducted during the Recertification Survey 01/03/2024 to 01/10/2024, the facility did not ensure that the most recent hospice plan of care was provided for a resident. Specifically, the Hospice Assessment, Plan of Care and Hospice team interdisciplinary notes were not provided to the facility and available for review for Resident #87. This was evident for 1 of 1 resident reviewed for Hospice out of 38 sampled residents.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 01/03/2024 to 01/10/2024, the facility did not ensure that the nurse staffing information was posted appropriately. Specifically, the posting of daily nurse staffing information was not posted in a prominent area which was readily accessible to residents and visitors. The finding is: The facility policy and procedure titled Posting Daily Nurse Staffing Information dated 1/23 documented that it is the policy of our facility to ensure nurse staffing information is readily available in a readable format to residents and visitors at any given time. During observations conducted on 01/03/2024, 01/05/2024 and 01/08/2024, the State Surveyor was unable to locate the postings of the daily nurse staffing levels for each shift or any signage instructing residents or visitors where it was located. [...]

Inspectors wroteBased on record reviews and interviews conducted during Recertification and an Abbreviated survey (NY00250610 and NY00253209), the facility did not ensure that person-centered care plans with measurable goals, time frames, and interventions were developed to address resident's concerns. Specifically: 1) A care plan was not developed to address a resident's oxygen use. 2) A care plan was not developed to address a resident with aggressive behavior. 3) A Care Plan was not developed to address a resident's actual skin breakdown and risk for further skin breakdown. 4) A Care Plan was not developed with interventions documneted to prevent further skin breakdown. This was evident for 4 residents out of a total of 38 sample residents reviewed. (Resident #105, #209, #306 and #25)

Inspectors wroteBased on observation and interviews conducted during the Recertification survey, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag was uncovered and exposed to public view. This was evident for 1 of 38 sampled residents (Resident #170). The finding is: The facility policy and procedure titled Catheter Care Urinary dated 08/2021 did not indicate how staff would assist residents with Foley catheter care to maintain their dignity and privacy. Resident # 170 was admitted to the facility on [DATE] with diagnoses that include Hypertension, Chronic Kidney Disease, and Benign Prostatic Hyperplasia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident #170 with cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of 10/15. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that a resident's assessment was accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that a resident was not on Hospice Care. This was evident for 1 out of 1 resident's reviewed for Hospice Care out of an investigative sample of 38 residents. (Resident #202)

Inspectors wroteBased on record reviews and interviews conducted during recertification and complaint (NY00250610) survey, the facility did not ensure that a resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcer unless the individual's clinical condition demonstrate that they were unavoidable. Specifically, two residents at risk for pressure ulcers were not provided with preventive skin care to prevent skin breakdown and pressure ulcers upon admission. This was evident for 2 out of a total of 38 sample residents reviewed. (Resident # 309 and #25)

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did ensure a resident's personal privacy was maintained. Specifically, a resident was observed in the room without a privacy curtain. This was evident for 1 resident out of a total of 38 sampled residents reviewed. Resident #25 Resident #25 was admitted to the facility on [DATE] with diagnoses that include Parkinson's disease, Vascular Dementia with behavioral disturbance and Dysphagia. The Quarterly Minimum Data Set (MDS) dated [DATE], documented that resident was cognitively severely impaired. The resident required total assistance of two persons assist for bed mobility, transfers, and toileting. On 11/3/21 at 11:14 AM, Resident #25 was observed lying on back in bed. Surveyor did not observe pillows nor heel booties. There was no privacy curtain. [...]