King David Nursing And Rehabilitation Center

Investigation of Alleged Abuse, Neglect, and Exploitation, letter A read that an immediate investigation was warranted when there was suspicion of abuse, VI.

Protection of the Resident letter D read that room or staffing changes were to be made, if necessary to protect the resident (s) from the alleged perpetrator.

Section VII.

Reporting/Response, letter A read the facility would have written procedures that included: 1. reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies. 1a. immediately, but no later than 2 hours after the allegation is made.

During a review of the facility's investigation file for the facility reported incident #2725522 on 2/24/26 at 10:00 AM it was revealed on the initial report form that an allegation of abuse for Resident #5 was reported to Registered Nurse (RN) #11 on 1/23/26 at 8:30 PM.

The administrator was not made aware of the abuse allegation until 11 hours later by the DON on 1/24/26 at 7:30 AM.

According to the report the resident told the nurse that Geriatric Nursing Assistant (GNA) #12 had rolled him/her over in bed causing them to hit their head on the bedrail.

Further review revealed the email confirmation the report was submitted to the state agency on 1/24/26 at 9:25 AM by the Director of Nursing (DON). An interview with the DON on 2/25/26 at 11:32 AM revealed that she was not informed of the allegation of abuse until the following morning 1/24/26 at approximately 7:00 AM.

She stated that when she interviewed RN #11 the nurse reported that she was not sure if this was an allegation of abuse.

The DON reported that the employees know they can call her at any time, however this nurse failed to call immediately.

Furthermore, GNA #12 continued to work the rest of her shift until 11:00 PM with vulnerable residents. On 2/25/26 at 12:13 PM the concerns were reviewed with the Nursing Home Administrator who offered no rationale for the deficient practice.

Cross Reference: F-F609 and F-F610

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

According to the initial report Resident #5 reported to Registered Nurse (RN) #11 that geriatric nursing assistant (GNA) #12 had rolled him/her over in bed and hit the resident's head on the bedrail on 1/23/26 at 8:30 PM.

However, she failed to report the allegation of abuse to the Director of Nursing (DON) until 1/24/26 at 7:30 AM, 11 hours later.

The confirmation email revealed the DON sent the allegation of abuse to the State Agency (SA) on 1/24/26 at 9:25 AM.

An interview with the DON on 2/25/26 at 11:32 AM revealed that her expectation was for staff to report allegations of abuse to her as soon as possible.

She stated that the nurse was unsure it was an allegation of abuse, but once she reported the incident to the DON, she was informed it was an allegation of abuse.

The DON stated that she reported it to the SA once she was made aware.

The concerns were reviewed with the Nursing Home Administrator on 2/25/26 at 12:13 PM.

Cross Reference: F-F607 and F-F610

• On 02/20/26 at 2:09 pm the surveyor received a copy of the email that was received by the facility

when the final report of the investigation related to Resident # 3 was submitted.

The facility staff submitted an allegation of abuse on 10/21/25.

According to the email received from Administrator #1 on 02/20/26 at 2:09 pm, the 5-day final report was submitted on 10/29/25.

Five working days after the initial report was submitted would have been 10/28/25.

The report was submitted to the state agency a day late.

On 02/20/26 at 2:47 pm during an interview with Director of Nursing (DON) #2 the surveyor asked what timeframe the results of an investigation should be submitted to the state agency. DON #2 verbalized they have 5 days to submit the follow-up investigation results.

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

10:00 AM revealed on the initial report from that Resident #5 reported an allegation of abuse on

indicated she worked 2 1/2 hours after the allegation of abuse. On 1/24/26 she came in at 7:30 am and clocked out at 8:30 am at which time she was suspended as reported by the Director of Nursing (DON) in a later interview.

An interview with the DON on 2/25/26 at 11:32 AM revealed RN #11 failed to notify her of the allegation of abuse immediately.

She stated the nurse should have called even if she was not sure it was an abuse allegation.

She stated that was the reason that the GNA was allowed to continue to work that evening because she would have suspended the GNA immediately.

The concerns were reviewed with the Nursing Home Administrator on 2/25/26 at 12:13 PM who offered no rationale for the deficient practice.

Cross Reference: F-F607 and F-F609

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

admission; and must tell residents what care they do not provide.

minimal harm Based on record review and interview, it was determined that the facility admission agreement failed to include special characteristics and service limitations related to a kosher diet, and requested

The findings include:On 2/19/26 at 1:51 PM a review of the admission packet revealed the admission Agreement. A review of this document failed to reveal information regarding the facility's kosher diet.

In addition, the document requires the resident and sponsor agree to not hold the facility responsible for injury or harm that could have been avoided if they had hired a private duty nurse.Further review revealed a Risk Acknowledgement.

This form outlined the facility was not responsible for stolen, lost, or damaged personal property and were not responsible for the development of pressure sores, despite regulatory requirements prohibiting waiver of potential facility liability for losses of personal property and regulatory requirement to provide a quality of care that included treatment and services to prevent pressure sores. A separate welcome packet included a copy of the Always Available Menu included in the packet which indicated that they served tuna salad, egg salad, turkey sandwich, bologna sandwich, and pastrami sandwiches along with some other items. At the bottom of the sheet it noted, Any alternate chosen must reflect the kosher appropriate menu option (diary for dairy meal, meat for meat meal.) However, there was no other mention of the special dietary considerations in the welcome packet.An interview with the Hospital Liaison on 2/20/26 at 9:34 AM revealed that she was the person who talked to potential residents in the hospital.

She stated that they do not let the residents and/or resident's family know prior to admission and in writing that they follow a kosher diet.

She stated that she may mention it but does not go into any detail as to what it means unless they ask for further information.

She stated, Food is food and it should not make a difference that meat and dairy cannot be served in the same meal.The Nursing Home Administrator (NHA) was asked to provide proof that the admission policy/agreement was approved at the time of the change in ownership on 2/24/26 at 10:06 AM via a phone call and it was clarified with him on 2/24/26 at 10:14 AM. He was asked on 2/25/26 at 12:19 PM for the information.

However, he failed to provide the evidence.On 2/26/26 at 12:33 PM an interview with the NHA revealed he was unable to provide proof that the admission agreement was approved during the change in ownership in 2017 and confirmed that residents were not informed in writing prior to admission that they followed a kosher diet. He stated that it may be included in a brochure, but that he cannot be certain that it was given to every resident. In addition, the surveyor had asked for all information that was provided before and at the time of admission and he failed to provide such a brochure. He offered no rationale as to why the admission agreement and risk acknowledgement was not in compliance with the regulatory requirements.

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

On 12/16/26 at 2:46 pm an order was written for the resident to receive NaCl 1 Liter IV in the evening

administration record revealed (MAR) the nurses were not documenting the amount of IV fluids the

received should be written in the notes. On 02/25/26 at 3:30 pm during an interview with LPN Unit Manager #10 the surveyor asked if a resident's medication is not available on site, what do they do? LPN Unit Manager #10 verbalized if they can't get the medication prescribed they would get something that is equivalent and call the pharmacy to get a STAT dose.

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

Federal health inspectors cited KING DAVID NURSING AND REHABILITATION CENTER in BALTIMORE, MD for a deficiency under regulatory tag F-F0803 during a complaint investigation conducted on 2026-02-26.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of KING DAVID NURSING AND REHABILITATION CENTER.

Correction Status: Deficient, Provider has no plan of correction.

a.

There was a bag of sugar sitting on the floor. c.

There were lids and debris on the floor. d. An air conditioning unit that was vented through the wall had 3 boxes piled on tubing. e.

There were bags of portion cups stored on the floor.

On 2/18/26 at 1:00 PM an interview with [NAME] #23 revealed they had received a shipment of boxes that day.

When shown the other supplies on the floor he acknowledged that they were not from the recent delivery.

On 2/18/26 at 1:02 PM dietary Staff #24 was observed to be preparing lunch and failed to have a hair and beard restraint on.

On 2/19/26 at 1:30 PM an observation of dietary Staff #25 was observed preparing food portion cups for storage and failed to have on a hair and beard restraint.

An interview with the Dietary Manager on 2/26/26 at 12:03 PM revealed he was responsible for ensuring the kitchen was cleaned and maintained, and that staff were wearing the appropriate hairnets and beard nets. He stated that he was addressing maintenance issues with the Maintenance Director, such as the leaking sinks, standing water on the floor, and the broken tiles due to environmental rounds that were completed on 2/3/26. He later provided an email outlining these concerns.

When asked about the cleanliness of the kitchen he stated that he was aware, however, had not addressed the issue. He stated that he was having issues with staff wearing the hair and beard restraints but had not addressed it with them.

The concerns were reviewed with the Nursing Home Administrator on 2/26/26 at 12:30 PM.

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

containers were closed and not overflowing with waste.

This deficient practice was evidenced in 4 of

include:On 02/24/26 at 1:28 pm while in the dining room located on Mount [NAME], the surveyor lifted the shade on the second window and observed 4 large waste containers.

The top lid of waste container #8320 was opened and large bags of rubbish were exposed at the top.

Also, a clear white bag was hanging off the left side of the waste container.

The left sliding door of the waste container #8319 was opened and a clear waste bag was hanging out the side.

The top lid of waste container #8213 was opened with brown boxes and waste bags exposed.

The lid to waste container #8148 was opened with clear waste bags exposed and hanging over the front of the large waste container.

There was waste on the ground on both sides of the container. On 02/24/26 at 1:24 pm during an interview with Maintenance Director #8, the surveyor asked what department is assigned to management the waste containers outside Maintenance Director #8 verbalized the Environmental Services Department oversees the dumpsters; the dumpsters are emptied Monday, Wednesday, and Friday. EVS oversees making sure the areas around the dumpsters are clean. On 02/25/26 at 1:24 pm during an interview with EVS Director #9 he/she verbalized the porters were supposed to know when the dumpsters are full to close them after they put the trash in.

All departments use the dumpsters, but the porters are responsible for ensuring they are closed.

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

in accordance with accepted professional standards.

failed to document when a resident received activities of daily living (ADL) assistance.

This deficient

findings include:On 02/25/26 at 8:39 am a review of Resident #6 ADL tasks for the months of December 2025 and January 2026 revealed there were multiple GNA tasks that were not completed during both months. On 12/24 & 12/25/25 (11 pm - 7 am), 12/26/25 (7am- 3 pm), and 12/31/25 (11 pm - 7am) there was no documentation to verify if the resident received personal hygiene care. On 12/24 & 12/25/25 (11 pm - 7am) 12/26/25, (7am-3pm), and 12/31/25 (11pm-7am) there is no documentation to verify the resident was turned and repositioned. On 01/03/26 (3pm-11pm) there was no documentation to verify the resident was turned and repositioned. On 01/03, 01/11, 01/18 during 11pm - 7am shift there was no documentation to verify if the resident was bathed.

There was no documentation on 01/03, 01/11, and 01/18/26 during 3pm-11pm shift to verify if the resident had an episode of bladder/bowel incontinence and if the resident received personal hygiene. On 02/25/26 at 9:42 am the surveyor reviewed Resident #6's ADL care documentation with LPN Unit Manager #5, the surveyor asked was the staff expected to document ADL care each shift. LPN Unit Manager #5 verbalized the expectation was for the documentation to be done; the documentation should have been completed by the end of the shift.

Once the task is completed they should document but if not it should be done by the end of the shift.

When a resident has an incontinence episode there should be documentation in the boxes.

The clinical staff is responsible for ensuring the staff completes the documentation of the care that was provided.

Chart reviews are done the day after the care was provided.

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

control practices.

This deficient practice was discovered during three observations of linen carts and

observation rounds the surveyor observed a linen cart outside of room [ROOM NUMBER] with a tube of cream, shower gel, a fan, and a bag of wash cloths on top on the linen cart.On 02/18/26 at 8:43 am the surveyor observed an uncovered linen cart outside of room [ROOM NUMBER].On 02/20/26 at 10:25 am the surveyor made Unit Manager #5 aware of the uncovered linen cart and the linen cart with items on top. LPN Unit Manager #5 verbalized the linen cart should have been covered and the items should not have been on top of the linen cart.On 02/20/26 at 10:30 am while in the shower room on Sudbrook with LPN Unit Manager #5 the surveyor observed a used washcloth on the grab bar in the shower stall and two used washcloths and a towel on the floor in front of the first shower stall.LPN Unit Manager # 5 verbalized the Geriatric Nursing Assistants are supposed to clean up after using the shower room. To their knowledge Environmental Services cleans the shower room daily.

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King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208

outside to enter the room.

There were two other windows in the room which had large gaps in the

On 02/24/26 at 2:05 pm the surveyor demonstrated to Maintenance Director #8 the three set of

Administrator #1 was present at that time.

After surveyor intervention Maintenance Director #8 used a screwdriver to align the three set of windows; afterwards the gap in the windows were resolved.

• On 2/18/26 at 8:00 AM an observation of the facility parking lot revealed that there were discarded

face mask, gloves, water bottles, plastic cups, and other debris in the parking lot.

A second observation on 2/19/26 at 8:36 AM revealed that there were mask, gloves, plastic bottles, plastic straws, and other debris laying all over the parking lot and along the curb.

Along the right side of the parking lot was a tree line that had plastic bags stuck in the trees and bushes, plastic cups, paper, and other debris scatter.

The area in front of the building near the front door had mask, water bottles, plastic bags, broken plastic pieces lined against the building.

The porch area at the entry door had a trashcan with debris laying near it, a broken orange snow shovel, and black plastic piece, plastic bags, and paper laying in the grass to the left.

On 2/19/26 at 10:00 AM met with the Nursing Home Administrator (NHA), Maintenance Director, and EVS Director.

When asked who was responsible for cleaning up the debris in the parking lot. EVS stated that it was housekeeping's responsibility.

Reviewed findings with the EVS Director with the NHA present on 2/19/26 at 10:03 AM by walking around the parking lot and showing her the debris.

She stated that she assigns a porter everyday to clean the parking lot area.

When asked who monitors if it was done or not, she stated that she does.

She stated that she has not checked the area since they had snow.