Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Based on observations, staff interviews, and review of the employee handbook, the facility failed to ensure
residents were free from potential neglect when staff were sleeping while on duty. This had the potential to
affect all 35 residents (#17, #27, #35, #47, #56, #62, #70, #76, #83, #92, #98, #102, #109, #120, #129,
#131, #142, #143, #147, #150, #151, #161, #163, #165, #198, #213, #219, #221, #229, #231, #232, #233,
#236, #246, #250) residing on the Beachwood Pavilion unit and the potential to affect all 55 residents (#3,
#4, #11, #13, #18, #19, #20, #34, #36, #37, #42, #46, #54 #63, #66, #84, #86, #91, #94, #95, #99, #101,
#103, #110, #113, #119, #123, #124, #126, #128, #133, #154, #156, #158, #160, #166, #168, #169, #172,
#179, #181, #185, #187, #194, #199, #201, #202, #205, #210, #218, #227, #234, #238, #252, #262)
residing on the Euclid Pavilion Unit. The facility census was 264.
Findings include:
Observation on 10/20/24 at 6:21 A.M. of the Beachwood Pavilion unit nursing station revealed Licensed
Practical Nurse (LPN) #1001 was seated at the nursing station desk. The employee's head was observed
tilted downward and the employee's eyes were closed. The State Surveyor attempted to arouse LPN #1001
by stating Good Morning, but LPN #1001 did not arouse. The State Surveyor attempted to arouse LPN
#1001 a second time. When the LPN aroused, the State Surveyor asked LPN #1001 if he/she was
sleeping, LPN #1001, smiled and rose from the desk and informed the State Surveyor the facility was
sufficiently staffed, and shift change would occur at 7:00 A.M.
Interview on 10/20/24 at approximately 6:30 A.M. with Registered Nurse (RN) #169 revealed all staff knew
the rules as it pertained to sleeping on the job and all staff were provided the same employee handbook.
RN #169 stated she did not know what to tell the State Surveyor as it related to the observation (of staff
sleeping), but RN #169 stated I do my job and they (other staff) should do theirs.
During the onsite survey, there were 35 residents, Resident #17, #27, #35, #47, #56, #62, #70, #76, #83,
#92, #98, #102, #109, #120, #129, #131, #142, #143, #147, #150, #151, #161, #163, #165, #198, #213,
#219, #221, #229, #231, #232, #233, #236, #246 and #250 who resided on the Beachwood Pavilion unit.
Observation on 10/20/24 at 6:33 A.M. of the Euclid Pavilion unit revealed State Tested Nursing Assistant
(STNA) #362 was observed sitting in a chair with the chair back against the wall. The STNA's head was
observed resting on the wall, eyes closed, and mouth ajar. The State Surveyor attempted to arouse STNA
#362 three times, but was unsuccessful. The State Surveyor leaned forward to speak louder in a fourth
attempt to arouse STNA #362 which was successful. STNA #362 opened his/her eyes while stating
residents on the unit were just waking up and getting prepared for the breakfast meal. STNA #362
confirmed, verified, and apologized for sleeping while on duty.
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
365094
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview on 10/20/24 at 7:00 A.M. with Night Supervisor Licensed Practical Nurse (LPN) #157 revealed
she had been trying to locate the State Surveyor to open the conference room. The State Surveyor
informed LPN #157 that staff were observed sleeping on the night shift. No additional information was
provided from the LPN in regard to staff observed sleeping on duty.
During the onsite survey, there were 55 residents, Resident #3, #4, #11, #13, #18, #19, #20, #34, #36, #37,
#42, #46, #54 #63, #66, #84, #86, #91, #94, #95, #99, #101, #103, #110, #113, #119, #123, #124, #126,
#128, #133, #154, #156, #158, #160, #166, #168, #169, #172, #179, #181, #185, #187, #194, #199, #201,
#202, #205, #210, #218, #227, #234, #238, #252 and #262 who resided Euclid Pavilion Unit
Review of the employee handbook (dated 2024) employees received during orientation to the facility
included a section titled Work Rules: Employee Conduct and Work Rules that revealed an infraction that
may result in disciplinary action, up to and including termination of employment was sleeping while on duty.
Review of the handbook revealed the infraction was listed as item Number 20 (sleeping). Review of the
handbook revealed the facility did not implement the guidelines.
Interview with administration staff, including the Administrator and the Director of Nursing (DON), during the
course of the survey period dated 10/16/24 through 10/23/24 revealed during the hiring process, all new
employees were educated on conduct including not sleeping while on duty.
Review of the facility document titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of
Resident Property (last reviewed on 10/27/22), revealed the facility had a policy in place to ensure the
facility provided goods and services to residents to avoid physical harm, pain, mental anguish, or emotional
distress. Further review of the policy revealed all staff would be deployed, trained and qualified to meet the
needs of the residents and the Administrator would ensure all situations were communicated to and
coordinated with the Quality Assurance and Performance Improvement (QAPI) program and Quality
Assurance Committee to determine a need for systemic action. Review of the document revealed the facility
did not implement the policy to prevent potential incidents of neglect when staff were observed on duty and
sleeping.
This deficiency represents incidental findings of non-compliance investigated under Master Complaint
Number OH00159014.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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, interview and policy review, the facility failed to ensure resident meals were
palatable. This had the potential to affect 261 of 261 residents who received meal trays from the kitchen
with the exception of three residents (#99, #182, #204) who the facility identified as receiving no food by
mouth (NPO). The facility census was 264.
Residents Affected - Many
Findings include:
Interview on 10/16/24 at 10:15 A.M. with Resident #7 revealed the resident had concerns the food was not
good and was not hot when served.
Interview on 10/17/24 at 9:00 A.M. with Dietary Director (DD) #858 during tour of the kitchen and
kitchenettes revealed the dishwasher was currently not being utilized for the cleaning and sanitizing of
dishware for residents. DD #858 revealed all residents were served on disposable dishware and plastic
silverware. DD #858 stated the facility was currently waiting for additional parts (timeframe for parts to
arrive was not provided) to fix the dishwasher after it had not reached the required temperatures of at least
180 degrees Fahrenheit. DD #858 revealed the dishwasher was not being used to ensure the safety of the
residents when it pertained to meals being served from the kitchen.
Observation on 10/17/24 at 9:56 A.M. of the kitchen dishwasher revealed a final rise temperature of 186
degrees Fahrenheit. Observation revealed the dishwasher was safely meeting the final rinse cycle
temperature to wash and sanitize dishware to serve residents in the facility. DD #858 confirmed and verified
the dishwasher was meeting the appropriate rinse cycle temperature.
Interview and observation on 10/17/24 at 9:58 A.M. with Dietary Supervisor (DS) #812 revealed the
dishwasher was maintaining a final rinse cycle of 186 degrees Fahrenheit, but the facility was continuing to
use disposable dishware to serve residents meals. Observation of a wash and rinse cycle at the time of the
interview revealed the dishwasher was currently maintaining a final rinse cycle of 186 degrees Fahrenheit.
DS #812 revealed the minimum temperature should be 180 degrees Fahrenheit. DS #812 confirmed and
verified the observation at the time of the interview.
Interview on 10/17/24 at 10:10 A.M. with the Administrator revealed the dishwasher issues regarding the
final rinse cycle meeting required temperatures were actually resolved (date not provided ) but she made
the executive decision to not utilize the dishwasher for dishware until the entire dishwasher was fixed in
entirety (the facility had parts on order for additional work on the dishwasher at the time of the survey). The
Administrator revealed she was not using the dishwasher as a precaution.
Observation on 10/17/24 at 11:25 A.M. with Dietary Director (DD) #858 of the tray line revealed the lunch
meal consisted of breaded tilapia, green beans, grilled cheese, chopped potatoes, rice, and a chocolate
brownie. All food items were checked, and the following temperatures were recorded at the steam table: the
tilapia was 167 degrees Fahrenheit, the chopped potatoes were 174 degrees Fahrenheit, the grilled cheese
was 150 degrees Fahrenheit, the rice was 182 degrees Fahrenheit, and the green beans were 184 degrees
Fahrenheit. All food items were plated on disposable dishware with a plastic dome top, without warming
plates, and placed in the travel carts to be dispersed to each unit for serving.
A test tray of the lunch meal was completed on 10/17/24 at 11:50 A.M. with DD #858 on the memory
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
care unit. The test tray included breaded tilapia, green beans and grilled cheese. DD #858 utilized a digital
thermometer to check the temperatures of the food items. The breaded tilapia was 123 degrees Fahrenheit,
the grilled cheese was 118 degrees Fahrenheit, and the green beans were 121 degrees Fahrenheit. The
food items were flavorful, however they were only warm and not hot. The temperatures had dropped in
temperature in comparison to the temperatures taken at the steam table. DD #858 confirmed and verified
the food items were not hot at the time of the observation of the test tray.
Interview on 10/17/24 at 12:31 P.M. with Resident #87 revealed concerns with meal temperatures. The
resident stated staff had to re-warm her breakfast due to the eggs being cold and this had been occurring
for awhile.
Interview on 10/17/24 at 12:33 P.M. with Residents #36, #199, and #205 revealed the meals served from
the kitchen were barely hot and sometimes needed reheated in the microwave.
Interview on 10/17/24 at 12:35 P.M. with Resident #126 revealed the food was horrible.
Interview on 10/17/24 at 12:36 P.M. with Resident #54 revealed the meals were awful, not hot enough and
sometimes served cold.
Interview on 10/17/24 at 12:38 P.M. with Resident #243 revealed the food was not hot most of the time.
Interview on 10/17/24 at 12:40 P.M. with Resident #118 revealed the food was served hot sometimes.
Interview on 10/17/24 at 12:44 P.M. with Resident #89 revealed the food was not hot and it did not pertain
to any specific meal.
Interview on 10/17/24 at 12:46 P.M. with Resident #190 revealed the meals from the kitchen were served
cold and he could not eat it.
Interview on 10/17/24 at 12:47 P.M. with Resident #188 revealed she was upset about the lunch meal today
due to her fries (chopped potatoes) being cold and greasy. Resident #188 revealed her food was cold most
of the time.
Interview on 10/17/24 at 12:50 P.M. with Resident #226 revealed she was upset with her lunch meal.
Resident #226 revealed her food was normally cold, especially breakfast, and she had to have staff
re-warm her food.
A telephone interview on 10/17/24 at 4:06 P.M. with a General Parts Group Technician revealed he was
able to access the information to the facility and services provided. Interview revealed the facility
dishwasher previously had an issue with keeping the rinse cycle temperature sustained at a safe
temperature (180 degrees Fahrenheit) and was reading between 164 degrees Fahrenheit and 166
Fahrenheit degrees. Interview revealed the flow of water needed to be regulated and it required no
additional parts to correct. The technician revealed at the time of service on 10/15/24, the onsite technician
switched the gate valve to regulate the flow of water, and the rinse cycle temperatures were corrected and
held steady. Follow-up visits to the facility were not related to the dishwasher rinse cycle, however, it
required continued service due to the conveyor belt running slowly. Interview revealed the conveyor belt
concern with the dishwasher did not affect the rinse cycle temperatures, the issue was resolved.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
The service of food on disposable plates resulting in food being served that was not hot and palatable after
the facility dishwasher was repaired and functioning affected all residents, except three residents (#99,
#182, #204) who the facility identified as receiving no food by mouth (NPO).
Review of the facility document titled Food Preparation and Service (revised November 2022), revealed the
facility had a policy in place that food would be prepared, distributed, and served in a manner that complied
with safe food handling practices. Review of the policy revealed the danger zone for food temperatures was
above 41 degrees Fahrenheit and below 135 degrees Fahrenheit due to the temperature range promoted
rapid growth of pathogenic microorganism that caused food borne illnesses.
This deficiency represents incidental findings of non-compliance investigated under Master Complaint
Number OH00159014.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, review of the job descriptions, review of the employee handbook, and interviews, the
facility failed to have systems in place to ensure it was administered in a manner that enabled it to use its
resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and
psychosocial well-being of each resident. Administrative staff failed to ensure staff did not sleep while on
duty, failed to ensure staff did not have and/or utilize phones for personal use in resident care areas of the
facility and failed to ensure the kitchen dishwasher was utilized timely after repairs to ensure meals were
not served on disposable plates resulting in food being served from the kitchen that was not palatable.
Residents Affected - Many
This affected 15 residents (#95, #7, #87, #36, #103, #199, #205, #126, #54, #243, #118, #89, #226, #190
and #188) and had the potential to affect all 264 facility residents residing in the facility which included 35
residents who resided on the Beachwood Pavilion unit and 55 residents who resided on the Euclid Pavilion
unit. The facility census was 264.
Findings include:
Review of the undated job description for the Administrator revealed the Administrator reported to the Chief
Executive Officer (CEO) and essential job functions included, but were not limited to, overseeing and
ensuring the facility adhered to standards, norms, and government agency regulatory expectations, and to
ensure patient safety, and healthcare quality.
Review of the undated job description for the Director of Nursing (DON) revealed the DON reported to the
Chief Operating Officer (COO) and was responsible for assuring the residents care was optimal and met
and/or exceeded standards of nursing practice that included, but not limited to, providing supervision,
guidance, and direction to resident units and nursing personnel within each unit, assess, evaluate and
improve resident care, responsible for training, in-servicing, and evaluating staff.
Interviews with administrative staff, including the Administrator and the DON, during the course of the
survey period dated 10/16/24 through 10/23/24 revealed administration staff were aware of ongoing
concerns due to previous deficiencies issued by the State agency regarding staff on cell phones,
dishwasher maintenance and repair, and acknowledged during the hiring process, all new employees were
educated on conduct including personal use of cell phones while on duty.
The following new and continued concerns were identified during the on-site complaint survey and
correlated to a lack of effective administrative oversight:
a. Observation on 10/20/24 at 6:21 A.M. of the Beachwood Pavilion unit nursing station revealed Licensed
Practical Nurse (LPN) #1001 was seated at the nursing station desk. The employee's head was observed
tilted downward and the employee's eyes were closed. The State Surveyor attempted to arouse LPN #1001
by stating Good Morning, but LPN #1001 did not arouse. The State Surveyor attempted to arouse LPN
#1001 a second time. When the LPN aroused, the State Surveyor asked LPN #1001 if he/she was
sleeping, LPN #1001, smiled and rose from the desk and informed the State Surveyor the facility was
sufficiently staffed, and shift change would occur at 7:00 A.M.
Interview on 10/20/24 at approximately 6:30 A.M. with Registered Nurse (RN) #169 revealed all staff knew
the rules as it pertained to sleeping on the job and all staff were provided the same employee
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0835
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
handbook. RN #169 stated she did not know what to tell the State Surveyor as it related to the observation
(of staff sleeping), but RN #169 stated I do my job and they (other staff) should do theirs.
During the onsite survey, there were 35 residents, Resident #17, #27, #35, #47, #56, #62, #70, #76, #83,
#92, #98, #102, #109, #120, #129, #131, #142, #143, #147, #150, #151, #161, #163, #165, #198, #213,
#219, #221, #229, #231, #232, #233, #236, #246 and #250 who resided on the Beachwood Pavilion unit.
Observation on 10/20/24 at 6:33 A.M. of the Euclid Pavilion unit revealed State Tested Nursing Assistant
(STNA) #362 was observed sitting in a chair with the chair back against the wall. The STNA's head was
observed resting on the wall, eyes closed, and mouth ajar. The State Surveyor attempted to arouse STNA
#362 three times, but was unsuccessful. The State Surveyor leaned forward to speak louder in a fourth
attempt to arouse STNA #362 which was successful. STNA #362 opened his/her eyes while stating
residents on the unit were just waking up and getting prepared for the breakfast meal. STNA #362
confirmed, verified, and apologized for sleeping while on duty.
Interview on 10/20/24 at 7:00 A.M. with Night Supervisor Licensed Practical Nurse (LPN) #157 revealed
she had been trying to locate the State Surveyor to open the conference room. The State Surveyor
informed LPN #157 that staff were observed sleeping on the night shift. No additional information was
provided from the LPN in regard to staff observed sleeping on duty.
During the onsite survey, there were 55 residents, Resident #3, #4, #11, #13, #18, #19, #20, #34, #36, #37,
#42, #46, #54 #63, #66, #84, #86, #91, #94, #95, #99, #101, #103, #110, #113, #119, #123, #124, #126,
#128, #133, #154, #156, #158, #160, #166, #168, #169, #172, #179, #181, #185, #187, #194, #199, #201,
#202, #205, #210, #218, #227, #234, #238, #252 and #262 who resided Euclid Pavilion Unit
Review of the employee handbook (dated 2024) employees received during orientation to the facility
included a section titled Work Rules: Employee Conduct and Work Rules that revealed an infraction that
may result in disciplinary action, up to and including termination of employment was sleeping while on duty.
Review of the handbook revealed the infraction was listed as item Number 20 (sleeping). Review of the
handbook revealed the facility did not implement the guidelines.
Interview with administration staff, including the Administrator and the Director of Nursing (DON), during the
course of the survey period dated 10/16/24 through 10/23/24 revealed during the hiring process, all new
employees were educated on conduct including not sleeping while on duty.
b. Observation on 10/20/24 at 6:24 A.M. of the Beachwood Pavilion unit revealed STNA #374 was observed
sitting in the common area/dining room with a personal cell phone in the employee's hand and face
illuminated by the light from the phone. There were four (unidentified) residents also present in the area. As
the State Surveyor approached STNA #374, the cell phone was dimmed and placed in the pocket of STNA
#374's scrub pants. An interview with the STNA at the time of the observation verified she had been using
her phone and stated she was checking something.
Interview on 10/20/24 at approximately 6:30 A.M. with Registered Nurse (RN) #169 revealed staff knew the
rules as it pertained to talking on the phone as all staff were provided the same employee handbook. RN
#169 revealed she did not know what to tell the State Surveyor as it related to the observations (of staff
using their cell phone), but RN #169 stated I do my job and they (other staff) should do theirs.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0835
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Observation on 10/20/24 at 6:36 A.M. of the Euclid Pavilion unit revealed STNA #170 was observed inside
Resident #95's bathroom. Resident #95 was observed laying in bed. STNA #170 was heard from the
hallway talking loudly but conversation details were unclear. Resident #95 appeared sleep and not
engaging in conversation with STNA #170. STNA #170 was observed exiting Resident #95 room with a
telephone earpiece in the right ear. When the State Surveyor asked STNA #170 if they were on their phone,
STNA #170 stated they were not aware that State Surveyors visited facilities early or on the weekends.
STNA #170 did not answer or acknowledge the State Surveyor inquiry into phone use.
Interview on 10/20/24 at 7:00 A.M. with Night Supervisor LPN #157 revealed she had been trying to locate
state surveyor to open the conference room. The State Surveyor informed LPN #157 that staff were seen
utilizing their personal phones while on duty. LPN #157 revealed that staff were just informed of phone use
due to previous citations and all staff were aware of the phone policy upon hire.
Interview on 10/23/24 at 11:18 A.M. with Registered Nurse (RN) #169 revealed she disciplined staff in the
past for using their phone while working but could not remember dates or staff names.
Interview on 10/23/24 at 2:02 P.M. with Resident #103 revealed he had seen staff on their phones
sometimes, but he stated he tried not to acknowledge it because he did not like it.
Review of the undated job description for STNAs revealed the STNA reported to the nursing manager
and/or supervisor, and the DON and Assistant Director of Nursing (ADON). Review of the job description
revealed STNAs were responsible for providing a safe environment for residents and monitoring the
environment for safety.
Review of the employee handbook employees received during orientation to the facility, dated 2024,
included a section titled Work Rules: Employee Conduct and Work Rules that revealed an infraction that
may result in disciplinary action, up to and including termination of employment, was receiving or making
personal calls while on duty. Review of the handbook revealed the infraction was listed as item Number 47
(phones). Review of the handbook revealed the facility did not implement the guidelines.
c. Interview on 10/16/24 at 10:15 A.M. with Resident #7 revealed the resident had concerns the food was
not good and was not hot when served.
Interview on 10/17/24 at 9:00 A.M. with Dietary Director (DD) #858 during tour of the kitchen and
kitchenettes revealed the dishwasher was currently not being utilized for the cleaning and sanitizing of
dishware for residents. DD #858 revealed all residents were served on disposable dishware and plastic
silverware. DD #858 stated the facility was currently waiting for additional parts (timeframe for parts to
arrive was not provided) to fix the dishwasher after it had not reached the required temperatures of at least
180 degrees Fahrenheit. DD #858 revealed the dishwasher was not being used to ensure the safety of the
residents when it pertained to meals being served from the kitchen.
Observation on 10/17/24 at 9:56 A.M. of the kitchen dishwasher revealed a final rise temperature of 186
degrees Fahrenheit. Observation revealed the dishwasher was safely meeting the final rinse cycle
temperature to wash and sanitize dishware to serve residents in the facility. DD #858 confirmed and verified
the dishwasher was meeting the appropriate rinse cycle temperature.
Interview and observation on 10/17/24 at 9:58 A.M. with Dietary Supervisor (DS) #812 revealed the
dishwasher was maintaining a final rinse cycle of 186 degrees Fahrenheit, but the facility was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0835
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
continuing to use disposable dishware to serve residents meals. Observation of a wash and rinse cycle at
the time of the interview revealed the dishwasher was currently maintaining a final rinse cycle of 186
degrees Fahrenheit. DS #812 revealed the minimum temperature should be 180 degrees Fahrenheit. DS
#812 confirmed and verified the observation at the time of the interview.
Interview on 10/17/24 at 10:10 A.M. with the Administrator revealed the dishwasher issues regarding the
final rinse cycle meeting required temperatures were actually resolved (date not provided ) but she made
the executive decision to not utilize the dishwasher for dishware until the entire dishwasher was fixed in
entirety (the facility had parts on order for additional work on the dishwasher at the time of the survey). The
Administrator revealed she was not using the dishwasher as a precaution.
Interview on 10/17/24 at 12:31 P.M. with Resident #87 revealed concerns with meal temperatures. The
resident stated staff had to re-warm her breakfast due to the eggs being cold and this had been occurring
for awhile.
Interview on 10/17/24 at 12:33 P.M. with Residents #36, #199, and #205 revealed the meals served from
the kitchen were barely hot and sometimes needed reheated in the microwave.
Interview on 10/17/24 at 12:35 P.M. with Resident #126 revealed the food was horrible.
Interview on 10/17/24 at 12:36 P.M. with Resident #54 revealed the meals were awful, not hot enough and
sometimes served cold.
Interview on 10/17/24 at 12:38 P.M. with Resident #243 revealed the food was not hot most of the time.
Interview on 10/17/24 at 12:40 P.M. with Resident #118 revealed the food was served hot sometimes.
Interview on 10/17/24 at 12:44 P.M. with Resident #89 revealed the food was not hot and it did not pertain
to any specific meal.
Interview on 10/17/24 at 12:46 P.M. with Resident #190 revealed the meals from the kitchen were served
cold and he could not eat it.
Interview on 10/17/24 at 12:47 P.M. with Resident #188 revealed she was upset about the lunch meal today
due to her fries being cold and greasy. Resident #188 revealed her food was cold most of the time.
Interview on 10/17/24 at 12:50 P.M. with Resident #226 revealed she was upset with her lunch meal.
Resident #226 revealed her food was normally cold, especially breakfast, and she had to have staff
re-warm her food.
The service of food on disposable plates resulting in food being served that was not hot and palatable after
the facility dishwasher was repaired and functioning affected all residents, except three residents (#99,
#182, #204) who the facility identified as receiving no food by mouth (NPO).
A telephone interview on 10/17/24 at 4:06 P.M. with a General Parts Group Technician revealed he was
able to access the information to the facility and services provided. Interview revealed the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0835
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
facility dishwasher previously had an issue with keeping the rinse cycle temperature sustained at a safe
temperature (180 degrees Fahrenheit) and was reading between 164 degrees Fahrenheit and 166
Fahrenheit degrees. Interview revealed the flow of water needed to be regulated and it required no
additional parts to correct. The technician revealed at the time of service on 10/15/24, the onsite technician
switched the gate valve to regulate the flow of water, and the rinse cycle temperatures were corrected and
held steady. Follow-up visits to the facility were not related to the dishwasher rinse cycle, however, it
required continued service due to the conveyor belt running slowly. Interview revealed the conveyor belt
concern with the dishwasher did not affect the rinse cycle temperatures, the issue was resolved.
The facility failed to ensure effective administrative services were in place to monitor the service to the dish
machine to allow for staff to timely resume normal operation of the dish machine and discontinue the use of
disposable service ware to ensure food was served at the proper temperature and palatable .
This deficiency represents incidental findings of non-compliance investigated under Master Complaint
Number OH00159014.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, review of the facility policy, review of the Centers for Medicare and
Medicaid (CMS) directive related to Enhanced Barrier Precautions (EBP) and interview, the facility failed to
develop and implement an effective infection control program to ensure enhanced barrier precautions
(EBP) were maintained while wound care was performed for Resident #67. This affected one resident (#67)
of three residents reviewed for wound care. The facility census was 264.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #67 revealed an admission date of 06/21/24. Diagnoses included
multiple sclerosis, cognitive communication deficit, Crohn's disease, unspecified severe protein calorie
malnutrition, Parkinson's disease, major depressive disorder and neuromuscular dysfunction of bladder.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 10/01/24 revealed
Resident #67 had intact cognition and was dependent on staff for activities of daily living. Resident #67 had
an indwelling urinary catheter, and two unhealed Stage II pressure ulcers that were present on admission.
Review of the physician's orders for Resident #67 revealed no physician orders for EBP were in place
related to suprapubic catheter use and wounds care.
Review of the care plan dated 06/21/24 revealed Resident #67 had an actual pressure wound present on
admission as well as a suprapubic catheter due to neurogenic bladder. Intervention included to maintain
EBP while performing high-contact resident care activities.
Observation on 10/17/24 from 8:15 A.M. to 8:20 A.M. revealed Licensed Practical Nurse (LPN) #835
knocked on Resident #67's door and entered. While Registered Nurse (RN) #842 was gathering needed
supplies, LPN #835 cleansed the resident's bedside table. RN #842 placed wound care supplies on
bedside table and both LPN #835 and RN #842 then washed their hands and applied (donned) gloves (no
gown was applied), then both staff proceeded to assist Resident #67 to turn onto the resident's side to
allow RN #842 to complete the dressing changes. RN #842 removed soiled dressings, removed (doffed)
gloves, cleansed hands and donned clean gloves. Nurse Practitioner (NP) #1000, who was present also,
was observed to cleanse his/her hands and donned gloves (no gown applied) then proceeded to measure
Resident #67's hip and coccyx wound. RN #842 then placed new dressings on the resident's coccyx and
hip wounds. RN #842, LPN #835 and NP #1000 removed their gloves, performed hand hygiene and exited
the resident's room.
Interview on 10/16/24 at 8:22 A.M. with RN #842, LPN #835, and NP #1000 confirmed they did not wear
gowns while performing high contact (wound) care for Resident #67. RN #842 further stated she had not
worn a gown since Resident #67 did not have Methicillin-Resistant Staphylococcus aureus (MRSA).
Interview on 10/17/24 at 3:23 P.M. with the Director of Nursing (DON) revealed the staff did not write an
actual physician order for EBP; however, the need for EBP was identified in the resident's plan of care.
Review of facility policy titled Enhanced Barrier Precautions, dated 04/01/24), revealed enhanced barrier
precautions were used in conjunction with standard precautions and expand the use of personal
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
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
365094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/23/2024
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that
provide opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing.
EBP was indicated for residents with wounds and indwelling medical devices such as urinary catheters.
Review of the Centers for Medicare and Medicaid, Center for Clinical Standards and Quality/Quality, Safety
& Oversight (QSO) Group memorandum summary, reference number QSO-24-08-NH, issued 03/20/24,
revealed EBP in long-term care facilities became effective on 04/01/24 to align with nationally accepted
standards. The QSO memorandum further revealed EBP was to include residents with chronic wounds
and/or indwelling medical devices, including feeding tubes and tracheostomies, during high contact care
regardless of their status related to multi-drug-resistant organisms.
This deficiency represents incidental findings of non-compliance investigated under Complaint Number
OH00158514.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365094
If continuation sheet
Page 12 of 12
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the October 23, 2024 survey of KING DAVID POST ACUTE NURSING & REHABILITATION LLC?
This was a inspection survey of KING DAVID POST ACUTE NURSING & REHABILITATION LLC on October 23, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at KING DAVID POST ACUTE NURSING & REHABILITATION LLC on October 23, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.