Inspection Reports for King David Center For Nursing And Rehabilitation
NY, 11214
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 3, 2025
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey to evaluate compliance with regulations related to resident safety, care planning, abuse reporting, environmental maintenance, and food safety.
Complaint Details
The complaint investigation revealed failures in timely reporting of abuse and injuries of unknown origin for Residents #63, #145, and #12. The facility did not report these incidents to the New York State Department of Health within required timeframes despite policies mandating prompt reporting.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to maintenance and housekeeping deficiencies across multiple units. The facility also failed to timely report suspected abuse and injuries of unknown origin to the New York State Department of Health for several residents. Additionally, comprehensive care plans were not reviewed and revised to reflect residents' current behavioral and wandering issues. Food safety violations were observed including improper hair covering by kitchen staff, expired food items, and staff handling food with bare hands.
Deficiencies (4)
Failure to maintain residents' right to a safe, clean, comfortable and homelike environment due to housekeeping and maintenance deficiencies in multiple units.
Failure to timely report suspected abuse, neglect, or injuries of unknown source to the New York State Department of Health for 3 residents.
Failure to develop and revise comprehensive care plans to address residents' behavioral problems and elopement/wandering risks.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including improper hair covering, expired food, and bare hand contact with food.
Report Facts
Residents reviewed: 35
Residents affected: 3
Ripped window screens: 6
Staples: 3
Lacerations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding maintenance issues and staffing shortages | |
| Director of Nursing | Director of Nursing Services | Interviewed regarding reporting requirements and care plan reviews |
| Housekeeping Director | Interviewed about housekeeping responsibilities | |
| Administrator | Interviewed about renovations, reporting policies, and food safety | |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about Resident #164 behavior |
| Registered Nurse #1 | Registered Nurse | Interviewed about care plan reviews and Resident #164 behavior |
| Registered Nurse #3 | Registered Nurse | Interviewed about care plan updates for Resident #116 |
| Dietary Aide #2 | Dietary Aide | Interviewed about hair covering in kitchen |
| Food Service Director | Interviewed about kitchen hair covering and food storage | |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Observed and interviewed regarding bare hand contact with food |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about dining room monitoring and food handling |
| Infection Preventionist | Interviewed about hand hygiene importance |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 10, 2024
Visit Reason
The inspection was conducted as a Recertification/Complaint survey from January 4, 2024 to January 10, 2024 to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
The visit was complaint-related as it included a Recertification/Complaint survey. Specific complaints included lack of resident participation in care planning, non-functional call bell, inaccurate assessments, improper posting of staffing info, dietary issues, and hospice documentation deficiencies.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, non-functional call bell in a resident's bathroom, inaccurate resident assessments, improper posting of nurse staffing information, failure to follow dietary preferences and menus, and lack of provision of hospice documentation for a resident.
Deficiencies (6)
Facility did not ensure resident participation in the development and implementation of person-centered care plans.
Call bell in resident's bathroom was not working, affecting emergency communication.
Admission assessment did not accurately reflect presence of a colostomy device for a resident.
Nurse staffing information was not posted in a prominent, readily accessible area for residents and visitors.
Menus and dietary preferences were not consistently followed; residents did not receive food items as ordered or preferred.
Facility did not ensure the most recent hospice plan of care was provided and available for review for a resident receiving hospice services.
Report Facts
Residents reviewed: 38
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #2 | Social Worker | Interviewed regarding resident participation in care planning |
| Director of Social Services | Director of Social Services | Interviewed about care planning meetings and documentation |
| Registered Nurse #6 | Registered Nurse | Interviewed about call bell system status |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed about call bell system status |
| Registered Nurse #7 | Registered Nurse | Interviewed about call bell system status |
| Director of Maintenance | Director of Maintenance | Interviewed about call bell repair plan |
| Director of Minimum Data Set assessments | Director of Minimum Data Set assessments | Interviewed about accuracy of resident assessments |
| Staffing Coordinator | Staffing Coordinator | Interviewed about nurse staffing information posting |
| Director of Nursing | Director of Nursing | Interviewed about nurse staffing information posting |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about dietary requests and food service communication |
| Food Service Director | Food Service Director | Interviewed about dietary service and kosher food restrictions |
| Registered Dietician | Registered Dietician | Interviewed about dietary concerns and resident food preferences |
| Administrator | Administrator | Interviewed about dietary service and meal tray audits |
| Registered Nurse Supervisor #8 | Registered Nurse Supervisor | Interviewed about hospice documentation availability |
| Hospice Registered Nurse #9 | Hospice Registered Nurse | Interviewed about hospice visits and documentation transmission |
| Home Health Aide #6 | Home Health Aide | Interviewed about hospice care instructions and plan of care |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about location of hospice documents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 10, 2024
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey from 01/03/2024 to 01/10/2024 to investigate complaints regarding the facility's failure to ensure menus and dietary preferences were followed for residents.
Complaint Details
The complaint investigation found that Resident #463 was denied a cheese sandwich due to kosher dietary rules despite requesting it for an outside appointment, and Resident #125 had missing food items on their meal tray. Interviews with nursing staff, Food Service Director, Registered Dietician, and Administrator confirmed these issues.
Findings
The facility failed to ensure that menus and dietary preferences were followed for 2 of 4 residents reviewed for food out of 38 sampled residents. Resident #463 did not receive a cheese sandwich as preferred due to kosher dietary restrictions, and Resident #125 did not receive all food items listed on their tray ticket during mealtime.
Deficiencies (1)
Failure to ensure menus and dietary preferences were followed, resulting in Resident #463 not receiving a cheese sandwich as preferred and Resident #125 missing food items from their tray.
Report Facts
Residents reviewed for food: 4
Total sampled residents: 38
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Made telephone calls to kitchen regarding Resident #463's sandwich request and provided statements about the incident |
| Food Service Director | Interviewed regarding kosher dietary restrictions and sandwich availability for Resident #463 | |
| Registered Nurse #1 | Registered Nurse | Interviewed about lunch bag procedures and Resident #463's meal before appointment |
| Registered Dietician | Registered Dietician | Interviewed about Resident #125's missing food items and dietary concerns |
| Administrator | Administrator | Interviewed about facility efforts to ensure residents receive proper meals and tray audits |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 10, 2021
Visit Reason
The inspection was a Recertification survey conducted to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity related to Foley catheter care, inaccurate resident assessments, incomplete care plans for oxygen use, aggressive behavior, and skin breakdown, inadequate pressure ulcer prevention and care, and lack of privacy curtains in resident rooms.
Deficiencies (5)
Resident's Foley catheter bag was uncovered and exposed to public view, violating dignity and privacy.
Minimum Data Set (MDS) assessment inaccurately documented that a resident was not on Hospice Care.
Care plans were not developed to address resident's oxygen use, aggressive behavior, and skin breakdown with measurable goals and interventions.
Residents at risk for pressure ulcers were not provided with preventive skin care to prevent skin breakdown and pressure ulcers upon admission.
Resident's room lacked privacy curtains, compromising personal privacy.
Report Facts
Residents sampled: 38
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Stage 4 Pressure Ulcer size: 3.2
Stage 4 Pressure Ulcer size: 4
Stage 4 Pressure Ulcer size: 0.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #4 | Unit Manager | Stated that residents with Foley catheters should have dignity bags |
| Licensed Practical Nurse #3 | LPN | Stated residents with Foley catheters are given leg bags when out of bed |
| Certified Nursing Assistant #4 | CNA | Described application of leg bags for residents with Foley catheters |
| Unit Manager #1 | Unit Manager | Discussed leg bag policy and care plan initiation |
| Director of Nursing | DON | Stated staff should ensure dignity bags for residents with Foley catheters and care plans for oxygen use and skin integrity |
| Assistant Director of Nursing | ADON | Discussed lack of care plan for aggressive behavior |
| Certified Nursing Assistant #1 | CNA | Discussed turning and positioning for Resident #309 with pressure ulcer |
| Wound Care Nurse | Wound Care Nurse | Discussed wound care and preventive measures for Resident #309 |
| Nurse Practitioner | NP | Discussed pressure ulcer care recommendations for Resident #309 |
| Certified Nursing Assistant #2 | CNA | Discussed repositioning and pressure ulcer care for Resident #25 |
| Licensed Practical Nurse #2 | LPN | Discussed wound care and repositioning for Resident #25 |
| Unit Manager #2 | Unit Manager | Discussed preventive interventions and CNA task implementation for Resident #25 |
| Housekeeping Director | Housekeeping Director | Explained missing privacy curtain for Resident #25 |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Apr 22, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including maintaining a safe and homelike environment, assessing residents for significant changes in condition, ensuring accurate assessments, developing comprehensive care plans, physician review of care, monitoring for unnecessary medications, and maintaining accurate medical records.
Deficiencies (8)
Facility did not maintain a safe, clean, comfortable and homelike environment; multiple resident rooms showed signs of disrepair including cracked walls, peeling paint, taped windows, and loose radiators.
Resident #203 was not assessed for a significant change in physical and medical status within 14 days after a fall and fracture.
Resident #74's assessment did not accurately document mood or signs of depression.
Care plans were not developed or updated to address residents' diagnoses and changes in condition, including residents #67, #74, and #203.
Physician did not review or document changes in care related to Resident #209's premature removal of IV line.
Resident #203 receiving Lovenox injections was not monitored for symptoms and side effects of anticoagulant therapy; bruising was observed but not documented or addressed properly.
Resident #67 received antipsychotic medication without documented evidence that it was necessary to treat a specific condition; gradual dose reductions were not attempted.
Resident #184's medical record contained inaccurate admission weights with no documentation to explain or correct the errors.
Report Facts
Deficiencies cited: 8
Resident sample size: 39
Medication administration days: 22
Weight discrepancy: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | MDS Assessor | Interviewed regarding significant change assessments for Resident #203 |
| RN #4 | Charge Nurse | Interviewed regarding Resident #203's fracture and wheelchair use, and bruising on Resident #203 |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding taped windows and care of Resident #203 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding bruising on Resident #203 |
| MD #1 | Physician | Interviewed regarding Resident #209's PICC line removal |
| MD #2 | Primary Physician | Interviewed regarding Resident #203's Lovenox bruising |
| RN #2 | Registered Nurse | Interviewed regarding care plan updates for Resident #67 |
| SW #1 | Social Worker | Interviewed regarding depression assessments and care plans |
| RN #3 | Unit Manager/Registered Nurse | Interviewed regarding Resident #67's medication fluctuations and behavior |
| DOM | Director of Maintenance | Interviewed regarding taped windows and maintenance issues |
| RN #4 | Charge Nurse | Interviewed regarding Resident #209's PICC line removal and care |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding care of Resident #67 |
| RN #4 | Unit Manager | Interviewed regarding Resident #184's weight discrepancy |
| ADNS | Assistant Director of Nursing | Interviewed regarding weight discrepancy for Resident #184 |
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