Judson Park

Based on record review and interview the facility failed to provide written information to the resident or resident representative regarding the facility bed hold policy upon discharge to hospital. This affected one (Resident #27) of three residents reviewed who required a bed hold notice. Findings include: Review of medical record for Resident #27 revealed an admission date of 08/26/24 and a discharge date of 09/02/24. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Review of the nurse progress note dated 09/02/24 timed at 8:30 P.M. revealed Resident #27's son, who was at the facility after a fall, requested staff to contact emergency services because of Resident #27's increased pain levels and long wait time for x-rays. At 8:45 P.M. emergency services arrived at the facility to transport Resident #27 to the hospital. Review of the nurse progress note dated 09/03/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview the facility failed to allow a resident to return to the facility after discharge to hospital for a change in condition. This affected one (Resident #27) of three residents reviewed who had been transferred to the hospital. Findings include: Review of medical record for Resident #27 revealed an admission date of 08/26/24 and a discharge date of 09/02/24. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Review of the nurse progress note dated 09/02/24 timed at 8:30 P.M. revealed Resident #27's son, who was at the facility after a fall requested staff to contact emergency services because of Resident #27's increased pain levels and long wait time for x-rays. At 8:45 P.M. emergency services arrived at the facility to transport Resident #27 to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure the medical record contained an accurate representation of the resident's actual experience. This affected one (Resident #27) of three residents reviewed for falls. Findings include: Review of medical record for Resident #27 revealed an admission date of 08/26/24 and a discharge date of 09/02/24. Diagnoses included restlessness and agitation, chronic kidney disease, Alzheimer's disease, and delirium due to known physiological condition. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/02/24, revealed Resident #27 had impaired cognition. Behaviors identified on the MDS included verbal and physical aggressiveness toward staff. Review of the plan of care dated 08/27/24 revealed Resident #27 was at risk for falls. Review of a nurse progress note dated 08/28/24 timed 3:08 P.M. revealed Resident #27 had a fall on 08/27/24. The progress note indicated that a fall mat and alarm were in place. The progress note provided no information regarding the time, place or specifics of the fall. Further review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #181, #184 and #186 had accurate advance directive orders and documentation in place for staff to accurately identify code status. This affected three Residents (#181, #184 and #186) out of five residents reviewed for advanced directives. The facility census was 25. Findings include: 1 Review of Resident #181's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of aftercare following joint replacement surgery, spinal stenosis lumbar, sleep apnea, osteoarthritis, Parkinson's disease, malignant neoplasm of prostate, myocardial infarction, and atrial fibrillation. Review of the physician's orders for Resident #181 revealed there were no orders to identify code status in the electronic medical record (EMR) or in the hard medical chart. Review of the facility document titled DNR Order Form, dated [DATE] and having Resident #181's name on it, revealed a physician signature, a large line…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and interview, the facility failed to ensure influenza vaccinations were offered to Resident #17, #185 and #186 at least annually. This affected three residents (Resident #17, #185, and #186) of five residents reviewed for vaccines. The faciliy census was 25. Findings include: 1 Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of normal pressure hydrocephalus, presence of cerebrospinal fluid drainage device, dementia, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for decision making and required extensive assistance of two plus for bed mobility, transfers, toileting, and was extensive assistance of one for hygiene, and dressing. Review of Resident #17's immunization records revealed he had an influenza vaccine on 10/20/21 and there was no evidence the facility offered an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure call lights were functioning and that needed repairs received timely intervention. This affected one of one residents (Resident #2) reviewed for environmental concerns. The facility census was 25. Findings include: Record review of Resident #2 revealed she was admitted to the facility 08/09/06 and had diagnoses including multiple sclerosis, dysphagia, wheelchair dependence, neuromuscular bladder dysfunction, and unspecified dementia. Her last Minimum Data Set 3.0 assessment on 10/29/22 revealed she had moderate cognitive impairment, was incontinent of bowel and bladder, and required extensive or total staff assistance for bed mobility, transfers, locomotion, hygiene, and toileting. Interview with Resident #2 on 01/17/23 at 10:21 A.M. revealed her call light had been broken for weeks. She shouted for help when she needed assistance and denied any negative effects from this. Observation at the time of the above interview revealed Resident #2's call light cord connected to a plastic box which appeared to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility did not ensure two residents (Residents #20 and #137) of five residents reviewed for unnecessary medications had as needed psychotropic medications addressed for necessity and a duration. The facility identified three additional residents who received as needed psychotropic medications, Residents #3, #4, and #8. Findings include: 1. Review of the medical record for Resident #20 revealed an admission on [DATE]. Diagnoses included pleural effusion, shortness of breath, irregular heartbeats, cancer, congestive heart failure and adjustment disorder with other symptoms. The medical record reflected on 02/05/20 the physician had placed an initial order for Lorazepam, an antianxiety medication, 0.5 milligram (mg) every two hours as needed for anxiety or restlessness. No stop date was indicated or stated on the order. An interview was completed on 03/03/20 at 4:50 P.M. with the Registered Nurse (RN) #502 and verified the lack of evidence of a 14-day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure medication was administered and secure for one resident (Resident #131) of 33 residents observed during the annual survey. The facility identified nine residents (Residents #1, #11, #13, #14, #15, #127, #129, #135 and #139) who were independently mobile with or without an assistive device. Findings include: Resident #131 was admitted to the facility on [DATE] with diagnoses including lung cancer, breast cancer, ovarian cancer, and status post intestinal obstruction with surgical repair. Review of Resident #131's medical record revealed a Brief Interview for Mental Status (BIMS) was completed on 02/28/20 where Resident #131 scored a 14 which demonstrated no cognitive impairment. Observation of Resident #131's bedside table on 03/02/20 at 9:55 A.M. revealed a breakfast tray which the resident was still eating off of, numerous toiletry items including tissues, a mirror, and brush, and a small plastic cup with five pills. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.