King David Post Acute Nursing & Rehabilitation Llc

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

it on to the aides that came in that he needed and wanted a shower but often the next day she would come

in and he still had not received the shower. Interview on 09/15/25 at 1:58 P.M. with the DON verified there were no shower sheets from 07/17/25 to 07/28/25 indicating Resident #8 had gone ten days without a bath and/or shower. There were also no shower sheet from 08/18/25 to 09/01/25 indicating Resident #8 had gone 12 days without a bath and/or shower. She was unable to identify who had given him a shower on 09/01/25, 09/04/25, 09/08/25 and 09/11/25 as the signature on the shower sheets was illegible and that

they had contacted the staff on duty for that day and were unable to determine who provided the shower.

She revealed they were still working on determining who had. Interview on 09/16/25 at 10:00 A.M. with the Administrator and DON revealed they were unable to determine which staff member signed off on the shower sheet for 09/01/25, 09/04/25, 09/08/25 and 09/11/25 as it is illegible and they contacted the staff on duty and were unable to determine who had provided Resident #8 the shower and/or bath for these days.

Review of the facility policy labeled, Resident Bath/ Showering/ Scheduling, dated 09/09/22, revealed residents would be bathed or showered according to their preference in order to maintain hygiene and skin condition. Each resident would be scheduled to receive bathing a minimum of two times per week unless

they prefer less frequently. When the bath or shower was completed, the staff would document on the shower sheet and/or the electronic record. If the bath or shower could not be given or the resident refused,

the nursing assistant would report to the charge nurse. The charge nurse would speak with the resident to determine alternative arrangements and document the refusal in the medical record. This deficiency represents non-compliance investigated under Complaint Numbers 2601023, 2562355, 1383330 (OH00166217), 1383336 (OH00165819), and 1383342 (OH00163342).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

King David Post Acute Nursing & Rehabilitation LLC

27100 Cedar Rd Beachwood, OH 44122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679

Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, observation and interview, the facility failed to ensure Resident #201 was offered activities to meet her preferences. This affected one resident (#201) of three residents reviewed for activities. The facility census was 259. Findings include:Review of the medical record for Resident #201 revealed an admission date of 07/19/23. Diagnoses included Alzheimer's disease, congestive heart failure, glaucoma, kidney disease and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed Resident #201 was severely cognitively impaired. She required setup help for eating, and supervision for oral hygiene, toileting dressing, showering and hygiene. It was very important to her to have books, newspapers and magazines to read, listen to music that she liked, be around animals, keep up with

the news, do things with groups of people, get fresh air outside and participate in religious services or practices. Review of the care plan dated 07/25/25 revealed Resident #201 would benefit from activities such as walking groups, discussions, keeping up with the news, ice cream socials, religious services and being outdoors. Interventions included assisting her with the television (TV) as needed, encouraging her to attend scheduled outdoor programming and religious activities, attending scheduled activities during the week such as music and special events and accepting room visits from life enrichment staff. Review of the activity calendar for July, August and September 2025 revealed no activities listed for the locked dementia unit where Resident #201 resided. Review of the activity participation note dated 08/26/25 revealed resident #201 enjoyed being social with others and liked to participate in activities such as music, art and games. Interview on 09/08/25 at 1:43 P.M. with Resident #201's granddaughter/guardian revealed the resident was often alone in her room when she came to visit. She would encourage her grandmother to leave her room while she was there, which the resident did willingly. Observation on 09/10/25 at 12:50 P.M. revealed Resident #201 was sitting at the end of the hallway holding a toy doll, she was pleasant and alert.

She was not involved in actives. Observation on 09/11/25 at 1:53 P.M. revealed Resident #201 was sitting by herself at the end of the hallway. She was not involved in activities. Observations of the locked dementia unit on 09/08/25, 09/09/25, 09/10/25, 09/11/25, 09/15/25 and 09/16/25 revealed no formal activities on the locked dementia unit. Review of the document titled Record of One-on-One Activities dated 08/04/25 through 09/12/25 revealed Resident #201 participated in music therapy six times and received a visit from activity staff eight times. She was described as chatty, talking, singing and dancing at various intervals throughout the events. Interview on 09/16/25 at 1:18 P.M. with Activity Director #845 revealed activities such as hand massages, music, walking and activity carts were available for residents on the locked unit where Resident #201 resided. She revealed Resident #201 participated in approximately one group activity in the past few weeks and did not normally attend group activities. She confirmed activity staff did not remind residents on the unit when a group activity was taking place or encourage participation. She also confirmed there were multiple activities that occurred outside of the locked unit; however, staff availability did not always afford the option for residents on the locked dementia unit where Resident #201 resided to attend those events. She acknowledged Resident #201 had an interest in activities such as music, animals, keeping up with the news, being with groups of people and other social events but could provide no additional evidence that those activities had been provided to or offered to Resident #201. She confirmed

the activity calendar for July, August and September 2025 did not identify specific activities that would occur

on the locked dementia unit where Resident #201 resided. This deficiency represents noncompliance investigated under Complaint Number 1383336 (OH00165819).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

King David Post Acute Nursing & Rehabilitation LLC

27100 Cedar Rd Beachwood, OH 44122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Review of the “Temperature Summary” in the electronic monitoring system from [DATE REDACTED] to [DATE REDACTED] revealed Resident #93's temperature: [DATE REDACTED] at 9:38 A.M. his temperature was 97.7 degrees Fahrenheit (F), [DATE REDACTED] at 9:19 A.M. his temperature was 98.4 degrees F, [DATE REDACTED] at 12:45 P.M. his temperature was 97.5 degrees F, [DATE REDACTED] at 5:14 P.M. his temperature was 98.2 degrees F, [DATE REDACTED] at 10:05 A.M. his temperature was 98.2 degrees F, [DATE REDACTED] at 3:34 A.M. his temperature was 96 degrees F, [DATE REDACTED] at 10:12 A.M. his temperature was 98 degrees F and [DATE REDACTED] at 11:06 P.M. his temperature was 98.7 degrees F. (There was no documented evidence that his temperature was assessed as ordered).

Review of the “Blood Pressure Summary” in the electronic monitoring system from [DATE REDACTED] to [DATE REDACTED] revealed Resident #93's blood pressure was obtained: [DATE REDACTED] at 12:09 A.M., 9:38 A.M. and 10:54 P.M., [DATE REDACTED] at 11:49 A.M., [DATE REDACTED] at 9:14 P.M., [DATE REDACTED] at 9:19 A.M.,12:45 P.M., 5:14 P.M., 8:47 P.M., [DATE REDACTED] at 9:17 A.M., 8:56 P.M., [DATE REDACTED] at 10:05 A.M., [DATE REDACTED] at 1:12 P.M., 9:37 P.M., [DATE REDACTED] at 8:00 A.M., 10:42 A.M., [DATE REDACTED] at 1:12 P.M., 10:08 P.M., [DATE REDACTED] at 9:40 A.M., 10:46 P.M., [DATE REDACTED] at 9:13 A.M., 1:30 P.M., 8:34 P.M., [DATE REDACTED] at 8:14 A.M., 10:14 P.M., [DATE REDACTED] at 3:34 A.M., 8:15 A.M., 3:19 P.M, 9:49 P.M., [DATE REDACTED] at 8:03 A.M. 8:42 P.M., [DATE REDACTED] at 10:02 A.M., [DATE REDACTED] at 8:06 A.M., 11:49 P.M., [DATE REDACTED] at 8:33 A.M., 3:06 P.M., 8:35 P.M., [DATE REDACTED] at 5:06 A.M., 1:06 P.M., 11:31 P.M., [DATE REDACTED] at 3:27 P.M., 10:57 P.M., [DATE REDACTED] at 8:37 A.M., 11:43 P.M., [DATE REDACTED] at 10:37 A.M., 10:49 P.M., [DATE REDACTED] at 8:06 A.M. 1:17 P.M., [DATE REDACTED] at 8:09 A.M., 1:05 P.M., 10:17 P.M., [DATE REDACTED] at 8:04 A.M., 1:07 P.M., 10:08 P.M., [DATE REDACTED] at 8:11 A.M., 1:01 P.M., 10:03 P.M., [DATE REDACTED] at 10:56 A.M., [DATE REDACTED] at 8:35 A.M., 1:14 P.M., [DATE REDACTED] at 12:00 A.M., 1:35 P.M., [DATE REDACTED] at 9:54 A.M., [DATE REDACTED] at 8:01 A.M., 1:07 P.M., 10:43 P.M., [DATE REDACTED] at 8:02 A.M., 1:42 P.M., 10:58 P.M., [DATE REDACTED] at 8:04 A.M., 1:03 P.M., 10:34 P.M., [DATE REDACTED] at 8:04 A.M., 10:58 P.M., [DATE REDACTED] at 9:37 A.M., 1:08 P.M., 10:36 P.M., 11:31 P.M., [DATE REDACTED] at 8:09 A.M. 1:09 P.M., [DATE REDACTED] at 8:02 A.M., 1:33 P.M., [DATE REDACTED] at 8:42 A.M., 1:11 P.M. 8:35 P.M., [DATE REDACTED] at 8:49 A.M., 1:16 P.M., 11:12 P.M., [DATE REDACTED] at 8:02 A.M., 1:00 P.M., 11:27 P.M. and [DATE REDACTED] at 9:00 A.M. His blood pressure varied during this time frame as his blood pressure ranged from 103/61 to 200/108. There was no blood pressure documented on [DATE REDACTED], and [DATE REDACTED]. (There was no documented evidence that his blood pressure was assessed as ordered).

Interview on [DATE REDACTED] at 1:58 P.M. with the Director of Nursing (DON) verified Resident #93 had an order dated [DATE REDACTED] that read the following: vitals every four hours (four times a day) for CHF. She verified that the nurse was just initialing on the TAR and that there was no documented evidence that vital signs were obtained as ordered. She verified vital signs including blood pressure, pulses, respirations, and temperatures were not assessed as ordered. She revealed she did not have a policy in regard to obtaining vital signs and the documentation of.

This deficiency represents non-compliance investigated under Complaint Numbers 2601023.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

King David Post Acute Nursing & Rehabilitation LLC

27100 Cedar Rd Beachwood, OH 44122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

use or the bed being in the lowest position. Review of the progress note dated 08/02/25 at 1:41 P.M. (this is

the progress note for the fall investigation above) revealed Resident #259 was found on the floor in his room between his bed and bedside table. His head was at the foot of his bed, and his feet were at the top of

the bed. Resident #259 was lying on his back with his wheelchair behind him facing the window. The resident was wrapped in his sheets and complained of back pain. No injuries were noted, his vital signs were blood pressure 131/62 heart rate 98 temperature 96 degrees F, respirations 18. The resident was placed back into bed, and his family and the supervisor were notified. Review of the significant change MDS 3.0 assessment dated [DATE REDACTED] revealed Resident #259 was severely cognitively impaired and required set-up help for eating, partial to moderate assistance for oral hygiene, chair/bed-to-chair transfers, and toilet transfers. He required substantial to maximum assistance for toileting, personal hygiene and showering. He was frequently incontinent of bowel and bladder. Observation on 09/11/25 at 7:20 A.M. revealed Resident #259 was lying asleep in his bed. A fall mat was noted to be folded up at the head of Resident #259's bed.

There was no bolster mattress on Resident #259's bed. Interview at the time of the observation with Certified Nurse Aide (CNA) #854 confirmed Resident #259 never had a bolster mattress to his bed, and there was not one in place at that time. He also confirmed the fall mat should have been spread out on the side of Resident #259's bed, and it had been implemented as an intervention as a result of the fall on 07/24/25. (The fall mat was not noted on the fall investigation or on the care plan). Interview on 09/15/25 at 2:16 P.M. with the Director of Nursing (DON) confirmed the fall investigations for Resident #259 did not have all the necessary information to consider the investigations complete and thorough. Review of the facility policy titled Fall Prevention and Management Policy, dated 12/09/19, revealed residents would be assessed for falls on admission, quarterly and as needed. If risks were identified, preventative measures would be put in place and care planned, and all falls would be reviewed and investigated. Individualized interventions would be implemented and added to the care plan accordingly. This deficiency represents noncompliance investigated under Complaint Number 1383335 (OH00166244).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

King David Post Acute Nursing & Rehabilitation LLC

27100 Cedar Rd Beachwood, OH 44122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

05/13/25 when the facility implemented the following corrective actions: By 05/01/25, all facility staff and residents were educated by Regional Nurse Director #672 using in-services and signs hanging on the units of the facility providing transportation to outside medical appointments when necessary either by the facility or insurance related transport. On 05/01/25, all unit managers were educated by Regional Nurse Director #672 on the process of ensuring residents' appointments and transportation needs were given to the transportation scheduler. On 05/13/25, Regional Nurse Director #672 and Previous Administrator #510 met with all the facilities and created the workflow schedule of the drivers to understand schedule availability.

On 05/13/25, Previous Administrator #510 educated the transportation coordinators to work together on the scheduling of appointments. On 05/13/25, Regional Nurse Director #672 educated the drivers and transportation coordinators that the dialysis residents were assigned to a specific driver and kept on their schedule to help with continuity. On 05/13/25, the transportation policy was reviewed by the interdisciplinary team including the unit managers and Regional Nurse Director #672. No changes to the policy were needed. Beginning 05/13/25, audits were conducted by Regional Nurse Director #672 or designee weekly for four weeks then monthly for two months. Results of the audits and any negative findings were forwarded to the QAPI (Quality Assurance and Performance Improvement) committee. On 05/22/25, Activities Coordinator #845 reminded all residents in the monthly Resident Council meeting of the facility providing transportation to outside medical appointments when necessary either by facility or insurance related transport. This deficiency represents non-compliance investigated under Complaint Number 1383325 (OH00163377).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

King David Post Acute Nursing & Rehabilitation LLC

27100 Cedar Rd Beachwood, OH 44122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

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. Resident #192 stated the food is bad, and she cannot eat it.

Interview on 09/08/25 at 3:54 P.M. Resident #272 stated the food is gross, cold, and not cooked properly.

Interview on 09/09/25 at 8:29 A.M. Resident #54 stated the food was okay, but not seasoned. Interview on 09/11/25 at 8:32 A.M. with Certified Nursing Assistant (CNA) #708 stated she hears a lot of residents complain about the food. They say they get small amounts of food and have to pay for food at the cafe.

Interview on 09/11/25 t 8:34 A.M. with Licensed Practical Nurse (LPN) #693 stated she hears a lot of food complaints from the residents. They have to go to the cafe and buy food because they do not like the food or they receive a small amount and are still hungry. Observation on 09/11/25 at 11:20 A.M. revealed the Interim Certified Dietary Manager (CDM) #508 was taking food temperatures for lunch from the steam table

in the kitchen. The eggplant cheese lasagna was 174 degrees Fahrenheit (F), the eggplant cheese lasagna with no tomato sauce was 151 degrees F, the veggie patty was 137 degrees F, the Italian green beans were 162 degrees F, and the puree Italian green beans were 134 degrees F. The veggie patties were pulled from

the tray line and heated to 160 degrees F. The pureed green beans were pulled from the line and heated to 170 degrees F. Meals were plated and placed on the meal cart to be taken to the unit. No thermal plate liners were used. On 09/11/25 at 11:41 A.M. a test tray was placed on the meal cart. At 11:47 A.M. the meal cart arrived at the Fairmount Pavilion, and the trays were immediately passed to the residents. At 11:58 A.M. all residents had been served their lunch. At 11:59 A.M. the food on the test tray was tasted by the surveyor and CDM #509, with Interim CDM #508 taking the temperatures. The eggplant cheese lasagna was 138 degrees F, the eggplant cheese lasagna with no tomato sauce was 123 degrees F, and the green beans were 121 degrees F. Interview with Interim CDM #508 verified the food temperatures of the eggplant lasagna with no tomato sauce, and the green beans were not at an acceptable service temperature for palatability at the time of the test tray. This deficiency represents non-compliance investigated under Complaint Number 2591287, 2562355, 1383326 (OH00163396) and 1383324 (OH00163342).

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet