King David Post Acute Nursing & Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at King David Post Acute Nursing & Rehabilitation LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 1, 2024

  Based on closed medical record review, review of a facility fall investigation, hospice staff interview, review of a hospice electronic mail (e-mail) correspondence, staff interview and review of facility policy, the facility failed to ensure physician ordered fall interventions were implemented and further failed to accurately report assessment findings and timely notify the attending physician and resident representative following a fall. Actual harm occurred on 09/15/24 at 11:00 P.M. when Resident #280, who was assessed to be at high risk for falls, sustained a fall from bed onto the floor without a physician ordered fall mat in place sustaining a fractured right clavicle (collarbone) and fracture at the sixth and seventh ribs. […]

• Actual harm, isolatedF686Nov 22, 2021

  Based on interview, closed record review and policy review, the facility failed to ensure adequate interventions and ordered treatments were implemented to identify a facility acquired pressure ulcer in an early stage and prevent the deterioration of a pressure ulcer. Actual Harm occurred on 10/01/21 when Resident #1 who required two-staff assist with bed mobility and was totally dependent of two-staff assistance with transfers was found to have an unstageable pressure ulcer (a wound caused by pressure that had full thickness tissue loss in which the base of the ulcer was covered by slough (nonviable dead tissue that is white or yellow in appearance) to the bilateral buttocks/coccyx area. Wound Physician (WP) #609 wrote a new treatment order on 10/01/21. […]

• Actual harm, isolatedF686Oct 28, 2021

  Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate care and services were provided for one resident (Resident #44) to prevent a pressure ulcer to the coccyx and buttock, and prevent pressure injuries to the right and left heels. Actual Harm occurred when care planned interventions were not implemented, physician orders were not followed, and a pressure ulcer to Resident #44's coccyx and buttock, and pressure injuries to the right and left heels were not treated or documented before they were identified as unstageable pressure ulcer/injuries. […]

• No harm, potential for more than minimal, widespreadF804Sep 22, 2025

  Based on observation, test tray and interviews, the facility failed to ensure meals were served at a safe and palatable temperature. This had the potential to affect all residents who received meals from the facility except for six residents (#1, #2, #101, #212, #240, and #261) identified by the facility as having orders for nothing by mouth (NPO). The facility census was 259. Findings include:Interview on 09/08/25 at 11:17 A.M. Resident #58 stated there was no good help in the kitchen. The food in the kitchen is strictly kosher, and she is not getting enough food. She stated sometimes the food is cold because there were not enough staff. By the time she gets her food, it's cold. She also stated the food comes from the kitchen late and it's not good. Interview on 09/08/25 at 12:28 P.M. […]

• No harm, potential for more than minimal, widespreadF804Oct 23, 2024

  Based on observation, interview and policy review, the facility failed to ensure resident meals were palatable. This had the potential to affect 261 of 261 residents who received meal trays from the kitchen with the exception of three residents (#99, #182, #204) who the facility identified as receiving no food by mouth (NPO). The facility census was 264. Findings include: Interview on 10/16/24 at 10:15 A.M. with Resident #7 revealed the resident had concerns the food was not good and was not hot when served. Interview on 10/17/24 at 9:00 A.M. with Dietary Director (DD) #858 during tour of the kitchen and kitchenettes revealed the dishwasher was currently not being utilized for the cleaning and sanitizing of dishware for residents. […]