King David Nursing: Abandoned Blood Pressure Pills - MD
The resident knew exactly what they were.
Resident #6, a patient at King David Nursing and Rehabilitation Center, told the inspector the pills were blood pressure medication from that morning's dose, that he had refused to take them, and that he had been tracking his own blood pressure readings because he had been told not to take the medication if his pressure ran too low. His reading that morning had been 110 over 66, with a pulse of 68. He interpreted that as too low and said no.
He was right to be cautious. The physician's order in his chart, dated January 27, 2026, instructed nursing staff to withhold Hydralazine if the systolic pressure dropped below 110 millimeters of mercury or the pulse fell below 60. His systolic reading that morning was exactly 110. Whether that reading crossed the threshold was a clinical judgment call, and it was not his call to make alone.
But nobody came back for the pills.
The medication administration record showed that LPN #2 had documented giving Resident #6 a dose of Hydralazine at 6 a.m., recording the same blood pressure and heart rate the resident described. The record said the medication was administered. The pills were still sitting in the cup more than eleven hours later.
Resident #6 had a perfect cognitive score. A mental status assessment on April 15, 2026 gave him a 15 out of 15 on the Brief Interview for Mental Status, indicating fully intact cognition. He tracked his own blood pressure readings in writing. He knew the name of his medication, knew why he had refused it, and recalled the exact numbers from that morning's reading without hesitation. He was not confused. He was unsupervised.
When the inspector alerted RN #1 to what was sitting on the bedside table, the nurse came to the room, saw the three pills, and removed them. That was the first time anyone had retrieved them.
The inspection was a complaint survey. Inspectors reviewed seven residents and found this problem with one. The citation covers a narrow slice of what happens during a medication pass at King David, but the mechanics of what went wrong are not complicated. A nurse documented giving a medication. The resident refused it. The pills were left where they sat, in an open cup, within reach, for the rest of the morning and into the evening.
The facility's own medication administration policy required staff to report and document any refusals. That documentation did not happen. The retrieval did not happen. What happened instead was that a cognitively sharp resident spent his day sitting next to a cup of his own heart medication, deciding for himself whether the numbers he had written down meant he should take it.
Hydralazine is prescribed to lower blood pressure in patients with hypertension. Leaving doses unsupervised after a refusal creates two problems running in opposite directions. A resident who changes their mind and takes a dose that was already charted as administered could receive a double dose. A resident who continues to refuse goes without a medication their physician ordered, with no clinical staff aware it was skipped.
Neither outcome was tracked here. The MAR said the medication was given. The cup said otherwise.
CMS assigned the violation a harm level of minimal harm or potential for actual harm, the lower end of the agency's scale. The citation covers accidents and supervision, the regulatory category requiring facilities to ensure the environment remains as free from accident hazards as possible.
Resident #6 was still seated in his wheelchair next to the bedside table when the inspector arrived that evening, the cup of orange pills within arm's reach, the morning already long gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for King David Nursing and Rehabilitation Center from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
KING DAVID NURSING AND REHABILITATION CENTER in BALTIMORE, MD was cited for violations during a health inspection on April 27, 2026.
The resident knew exactly what they were.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.