Judson Park

In the surveyor’s words

From the most serious findings on record at Judson Park, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 1, 2024

  Based on record review, interview, and policy review, the facility failed to ensure adequate supervision and individualized care planned interventions to prevent/reduce risk of falls and injury. This affected one resident (#27) of three residents reviewed who were at risk for falls. Actual harm occurred on 09/02/24 when Resident #27, who was identified as a high risk for falls, was found on the floor, unable to move her left leg and in severe pain. Resident #27 was sent to the hospital for evaluation and treatment where she was diagnosed with a fractured hip. Prior to the incident, Resident #27's scheduled sitter did not show up and the family nor the contacted company that provided the sitter were notified so arrangements for a replacement could be made. […]

• Actual harm, isolatedF689Mar 11, 2024

  Based on closed medical record review, staff interview, review of emergency medical services report, review of hospital records, review of facility policy, and review of manufacturer's guidelines, the facility failed to ensure resident safety during a Hoyer lift transfer. Actual harm occurred on 02/21/24 when Resident #30, who was cognitively impaired, at risk for falls and dependent on staff for transfers using a mechanical (Hoyer) lift, fell from the Hoyer lift during a staff assisted transfer resulting in hospitalization with injuries including a right frontal bone fracture extending into superior orbit, bilateral maxillary bone fractures, and bilateral inferior orbital wall fractures with involvement of right nasal lacrimal duct. […]

• No harm, potential for more than minimal, patternF880Jul 23, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure infection control protocols were maintained during medication administration for Resident #3 and during wound care for Resident #22. Additionally, the facility failed to ensure appropriate personal protective equipment was available and utilized for four residents (#1, #4, #26, and #45) who required enhanced barrier precautions. The facility identified seven residents who required enhanced barrier precautions. This affected six residents (#1, #3, #4, #22, #26, and #45) of seven residents reviewed for infection control. The facility census was 22. Findings include: 1. Record review revealed Resident #3 was admitted to the facility 04/15/24. […]

• No harm, potential for more than minimal, isolatedF625Oct 1, 2024

  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 admitted [DATE] and a discharge date of [DATE]. 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. […]

• No harm, potential for more than minimal, isolatedF626Oct 1, 2024

  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 admitted [DATE] and a discharge date of [DATE]. 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. […]