King David Nursing And Rehabilitation Center
KING DAVID NURSING AND REHABILITATION CENTER in BALTIMORE, MD — inspection on April 27, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
determined that the facility nursing staff failed to follow the physician's order for specific pulse and
(Resident #7) of 7 residents reviewed during a complaint survey.
The findings include: Review of Resident #7's closed clinical record on 04/22/26 revealed that Resident #7 was admitted to the facility on [DATE] with diagnoses that include a stroke, left eye blindness, and Alzheimer's type dementia. Resident #7 and had been deemed incapable of making all medical decisions by 2 attending physician on 12/11/25 and 12/12/25.
Further review of Resident #7's closed clinical record on 04/2/26 revealed a physician's order dated 12/17/2025 at 5 pm instructing the nursing staff to administer the medication, Nifedipine, 60 milligrams (mg), extended release, orally, every 24 hours, at bedtime (9 pm) for hypertension.
Hold the medication if the systolic blood pressure (SBP) is less than 110 or the heart rate is lower than 60 beats per minute. A review of Resident #7's December 2025 medication administration records (MAR) on 04/2/26 revealed the nursing staff failed to withhold the dose of Nifedipine on the following date and time: 12/20/25, 9 pm dose, with a documented pulse of 59 beats per minute.
These findings were shared with the facility director of nurses (DON) and the facility Administrator at the exit conference on 04/27/26 at 5 pm.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215022 04/27/2026
King David Nursing and Rehabilitation Center 4204 Old Milford Mill Road Baltimore, MD 21208
prevent accidents.
failed to provide supervision during a medication pass to ensure the medication was taken by the
residents reviewed during a complaint survey.
The findings include: During a tour of the facility on 04/23/26 at 5:15 pm, observation revealed 3 small round orange pills located in a medication administration cup on Resident #6's bedside table. Resident #6 was seated in the wheelchair which was next to Resident #6's bed and behind the bedside table. A staff member was observed assisting Resident #6 with the meal tray.
After greeting, Resident #6 was asked if the medication sitting on the bedside table was their medication. Resident #6 stated that the medication was their blood pressure pills from this morning and that he/she refused to take the medication. Resident #6 stated that he/she documents every blood pressure the nursing staff obtain before the nurse would administer the medication. Resident #6 stated that his/her blood pressure this morning was 110/66 with a pulse of 68 beats per minute. Resident #6 stated that they interpreted the blood pressure reading as being to low and that he/she was instructed not to take her blood pressure medication if the blood pressure reading was low. RN #1 was made aware and observed the 3 pills sitting in front of Resident #6.
The 3 pills were removed at that time. A review of Resident #6's medical record on 04/23/26 revealed a physician's order, dated 01/27/26, instructing the nursing staff to administer the blood pressure medication, Hydralazine, 25 milligram (mg) tablet, give three (3) tablets every 8 hours by mouth for Hypertension.
Withhold the medication for a systolic blood pressure reading of less than 110 Hg/mm or a pulse rate less than 60. A review of Resident #6's April 2026 medication administration record (MAR) revealed that LPN #2 administered a dose of Hydralazine to Resident #6 at 6 am and documented a blood pressure of 110/66 and a heart rate of 68 beats per minute. Resident #6 was assessed on 4/15/26 with a BIMS score of 15/15.
The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. A review of the facility policy for Medication Administration on 04/23/26 revealed a compliance guideline, #19, that instructs the nursing staff to report and document any adverse side effects or medication refusals.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.