King David Post Acute Nursing & Rehabilitation Llc
KING DAVID POST ACUTE NURSING & REHABILITATION LLC in BEACHWOOD, OH — inspection on September 22, 2025.
Found 6 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
Resident Bath/ Showering/ Scheduling, dated 09/09/22, revealed residents would be bathed or
frequently.
When the bath or shower was completed, the staff would document on the shower sheet
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).
365094 09/22/2025
King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] 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).
365094 09/22/2025
King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122
Review of the “Blood Pressure Summary” in the electronic monitoring system from [DATE] to [DATE] revealed Resident #93's blood pressure was obtained: [DATE] at 12:09 A.M., 9:38 A.M. and 10:54 P.M., [DATE] at 11:49 A.M., [DATE] at 9:14 P.M., [DATE] at 9:19 A.M.,12:45 P.M., 5:14 P.M., 8:47 P.M., [DATE] at 9:17 A.M., 8:56 P.M., [DATE] at 10:05 A.M., [DATE] at 1:12 P.M., 9:37 P.M., [DATE] at 8:00 A.M., 10:42 A.M., [DATE] at 1:12 P.M., 10:08 P.M., [DATE] at 9:40 A.M., 10:46 P.M., [DATE] at 9:13 A.M., 1:30 P.M., 8:34 P.M., [DATE] at 8:14 A.M., 10:14 P.M., [DATE] at 3:34 A.M., 8:15 A.M., 3:19 P.M, 9:49 P.M., [DATE] at 8:03 A.M. 8:42 P.M., [DATE] at 10:02 A.M., [DATE] at 8:06 A.M., 11:49 P.M., [DATE] at 8:33 A.M., 3:06 P.M., 8:35 P.M., [DATE] at 5:06 A.M., 1:06 P.M., 11:31 P.M., [DATE] at 3:27 P.M., 10:57 P.M., [DATE] at 8:37 A.M., 11:43 P.M., [DATE] at 10:37 A.M., 10:49 P.M., [DATE] at 8:06 A.M. 1:17 P.M., [DATE] at 8:09 A.M., 1:05 P.M., 10:17 P.M., [DATE] at 8:04 A.M., 1:07 P.M., 10:08 P.M., [DATE] at 8:11 A.M., 1:01 P.M., 10:03 P.M., [DATE] at 10:56 A.M., [DATE] at 8:35 A.M., 1:14 P.M., [DATE] at 12:00 A.M., 1:35 P.M., [DATE] at 9:54 A.M., [DATE] at 8:01 A.M., 1:07 P.M., 10:43 P.M., [DATE] at 8:02 A.M., 1:42 P.M., 10:58 P.M., [DATE] at 8:04 A.M., 1:03 P.M., 10:34 P.M., [DATE] at 8:04 A.M., 10:58 P.M., [DATE] at 9:37 A.M., 1:08 P.M., 10:36 P.M., 11:31 P.M., [DATE] at 8:09 A.M. 1:09 P.M., [DATE] at 8:02 A.M., 1:33 P.M., [DATE] at 8:42 A.M., 1:11 P.M. 8:35 P.M., [DATE] at 8:49 A.M., 1:16 P.M., 11:12 P.M., [DATE] at 8:02 A.M., 1:00 P.M., 11:27 P.M. and [DATE] 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], and [DATE]. (There was no documented evidence that his blood pressure was assessed as ordered).
Interview on [DATE] at 1:58 P.M. with the Director of Nursing (DON) verified Resident #93 had an order dated [DATE] 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.
365094 09/22/2025
King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122
Review of the significant change MDS 3.0 assessment dated [DATE]
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).
365094 09/22/2025
King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122
related transport. On 05/01/25, all unit managers were educated by Regional Nurse Director #672 on
met with all the facilities and created the workflow schedule of the drivers to understand schedule
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).
365094 09/22/2025
King David Post Acute Nursing & Rehabilitation LLC 27100 Cedar Rd Beachwood, OH 44122
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).
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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.