Judson Park Health Center

Inspectors wroteBased on interview and record review the facility failed to obtain and/or renew guardianship papers, and/or failed to provide assistance in the formulation of an Advanced Directive (AD - a document describing a resident's wishes for care if they became incapacitated) for 6 of 20 residents (Residents 5, 49, 9, 1, 2 & 54) reviewed for guardianship/advance directives. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer and/or discharge, or as soon as practicable for 3 (Residents 5, 10 & 82), offer a bed hold for 2 (Resident 10 & 82), notify the office of the Long Term Care Ombudsman (LTCO) for 1 (Resident 12), and provide discharge planning for 2 (Residents 1 & 43) of 7 residents reviewed for hospitalizations and discharges. These failures placed residents at risk of being uninformed about their discharge rights, the cost of holding the resident's bed while hospitalized , and a decreased quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before the transfer to a nursing home) assessments were accurate, revised, or submitted for a Level II PASRR assessment after the 30 day exemption expired for 5 (Resident 1, 2, 8, 12, & 55) of 8 sample residents and 1 (Resident 43) supplemental residents whose PASRRs were reviewed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct care conferences to ensure person-centered care for 3 (Residents 43, 4, & 53) of 4 residents reviewed for care planning, and failed to ensure Care Plans (CPs) were updated and/or revised, as needed for 2 (Residents 2 & 10) of 20 sample residents whose CPs were reviewed. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of non pressure skin conditions for 3 (Resident 40, 53, 1, & 54) of 5 and 1 supplemental (Resident 54) residents reviewed, and monitor and provide notification to the provider for low blood pressure readings for 1 (Resident 10) resident. These failures placed residents at risk for decline in medical status, unmet care needs, and a decreased quality of life.<Facility Policy>According to the facility's undated Care Plan, Comprehensive Person-Centered Care policy, a comprehensive, person centered care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and was developed and implemented for each resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate, investigate, and resolve grievances for 1 of 1 sampled residents (Resident 49) reviewed for grievances. This failure placed residents at risk for emotional distress, unresolved frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from unnecessary psychotropic medications for 3 (Residents 55, 1, & 2) of 5 residents reviewed for unnecessary medications. Staff failure to monitor residents for target behaviors, provide nonpharmacological interventions, and obtain consent for psychotropic medications placed residents at risk for receiving unnecessary medications and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS -an assessment tool) accurately reflected the status for 5 (Resident 43, 2, 5, 10, & 26) of 20 sampled residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (a process to determine what mental health services residents required after a Level 1 PASRR determined mental health services were necessary) were obtained for 3 (Residents 5, 10 & 26) of 8 residents whose PASRRs were reviewed. This failure placed residents at risk of not receiving necessary mental health care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were clarified for 4 (Residents 4, 40, 2, & 43,), order parameters were followed for 1 (Residents 53), and staff were signing only for tasks that were completed for 2 (Residents 1 & 2) of 20 sample residents reviewed. These failures placed residents at risk for medication errors, unmet care needs, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activity programs met the needs for 5 (Residents 1, 54, 2, 9, & 20) of 7 residents reviewed for activities. The failure to provide meaningful activities left residents at risk of boredom and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 23 sample residents (Resident 54) and one supplementary resident (Resident 1) reviewed for pressure injuries (injuries to the skin and underlying tissue caused by prolonged pressure) received the necessary care and services, consistent with professional standards of practice, to prevent new ulcers from developing, identify and treat PUs. Failure to complete weekly skin assessments, implement interventions, and describe and measure wounds placed residents at risk for skin deterioration, increased discomfort, new pressure injuries, and a diminished quality of lifeFindings included.<Facility Policy>According to the facility's revised April 2018 Pressure Ulcers/Skin Breakdown. policy the facility would assess residents' risk for pressure injuries and obtain orders from the physician for wound treatment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were implemented for 1 (Resident 43) of 8 residents reviewed for accidents, and failed to ensure the potential risks of an air mattress were assessed prior to implementation for 1 supplemental resident (Resident 1). These failures placed residents at risk for falls, injury, discomfort, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective pain management was provided to residents, consistent with professional standards of practice. The failure to offer non-pharmacological interventions to residents experiencing pain or investigate causes of pain for 3 of 5 sampled residents (Residents 6, 49 & 40) reviewed for pain management, placed residents at risk for untreated pain, unnecessary discomfort, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify triggers that might prompt a recall of previous traumatic events, and develop care planned goals and interventions for a resident who was a trauma survivor for 1 of 1 residents (Resident 67) reviewed for trauma informed care (a framework for understanding and responding to the effects of trauma). This failure placed the resident at risk for re-traumatization, psychological harm and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage and labeling of medications in 1 of 1 medication storage rooms (Cascade Hall), 2 of 3 medication carts (Cascade Hall and Shoreline Hall), and ensure medications were secured for 1 of 1 residents (Resident 2) reviewed for medication storage. These failures placed residents at risk of receiving expired medications, ineffective treatment, missing medications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 1 (Resident 43) of 1 sample residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was properly stored and labeled for 2 of 2 kitchens reviewed for kitchen safety. These failures left residents at risk for spoiled or contaminated foods, and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurses signed timely for the care provided for 1 (Resident 1) of 20 sample residents reviewed, and failed to ensure provider notes were added timely to the resident's record for 1 (Residents 9) of 1 resident reviewed for hospice and one supplemental resident (Resident 54). These failures placed residents at risk for an incomplete record of their care, unmet care needs, and delays in treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 2 of 2 residents (Resident 27 & 6) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); ensure staff used appropriate Hand Hygiene (HH) during resident care for 4 of 4 residents (Resident 27, 6, 37 & 54) who were observed for care; ensure staff followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 of 1 resident (Resident 37) reviewed for TBP; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure contact information of all pertinent State regulatory and informational agencies and advocacy groups were provided and/or posted in areas accessible to residents in a format and a language the residents understood for 8 of 8 residents (Residents 2, 22, 32, 25, 7, 38, 53, & 21) reviewed during Resident Council. This failure placed residents at risk for not being fully informed of their rights, potential abuse and/or neglect, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the information was documented showing the facility communicated necessary resident information to the receiving health care institution or provider for 3 of 5 sampled residents (Residents 56, 2, & 51) reviewed for hospitalizations. Failure to ensure necessary resident information was communicated to the hospital placed residents at risk for decreased quality of care, inadequate care/treatment, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge and notify the Office of the State Long Term Care Ombudsman (LTCO) of transfer/discharge for 5 of 5 sampled resident's (Residents 54, 28, 51, 56, & 2) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to ensure required notification of LTCO prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed hold (a process allowing residents who transfer from a facility temporarily to return to the same bed) policy, at the time of transfer or within 24 hours, for 5 of 5 sample residents (Resident 54, 28,51, 56 & 2) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CP) were updated and/or revised as needed for 3 of 18 sampled residents (Residents 20, 54, & 18) reviewed, and failed to ensure residents were provided an opportunity for a Care Conference (CC) for 1 of 18 sampled residents (Resident 40). Failure to ensure CPs were updated to reflect current care needs and residents were given the opportunity to participate in CCs left residents at risk for unmet care needs, lessened participation in care planning, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer the medications as ordered and to communicate with the provider to adjust the time for those medications while residents were out of the facility for dialysis (a procedure to clean and filter the body's waste products) treatment for 2 of 2 sampled residents (Resident 28 & 54) reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and prepared under sanitary conditions for 1 of 1 kitchen observed. Facility staff failed to: Label and date food; discard damaged/spoiled food; and perform Hand Hygiene (HH) during food preparation. The facility failed to ensure 1 of 2 resident refrigerators in the nursing units (Cascadia Neighborhood) were monitored for food brought in from outside sources. These failures contributed to an unsanitary and unsafe storage and preparation of food, and placed residents at risk for food-borne illness and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to initiate and thoroughly investigate incidents in a timely manner for Pressure Ulcer (PU) and unwitnessed falls for 2 of 3 sampled residents (Resident 40 & 54) reviewed for incident reports to rule out abuse and/or neglect. Facility failure to initiate an investigation for the cause of Resident 40's PU and Resident 54's falls within five days left residents at risk for repeated incidents and unidentified abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) of 2 of 18 residents (Residents 40 & 7) were completed accurately to reflect the resident's condition and overall health status. The facility failed to identify Resident 40's bilateral hand contractures and failed to capture Resident 7's active use of a wander guard device for elopement (to elope). These failures placed Residents 40, 7, and other residents at risk for unidentified and/or unmet care needs and continued unnecessary device use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with their Activities of Daily Living (ADLs) received the assistance they were assessed to require for 2 of 7 residents (Residents 18 & 40) reviewed for ADLs. The failure to provide clean-up care after eating assistance (Residents 18) and personal grooming care (Resident 40) left residents at risk for unmet care needs and a decreased self-worth, dignity or quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 residents (Resident 40) was provided physician ordered pressure relief interventions. Failure to implement use of off-loading boots, in accordance with the wound care team's recommendation, placed residents at risk for PU development, worsening of PU, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on facility staff for bowel and bladder (B/B) needs were accurately assessed to require for 1 of 4 residents (Resident 54) reviewed for B/B incontinence. Failure to accurately assess and provide care for Resident 54's B/B needs placed the resident at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure attempts to use appropriate alternatives prior to installing side rails were conducted and residents with side rails installed on their beds were: (1) assessed, evaluated, and did not pose as an entrapment risk, (2) risk and benefits were reviewed with the resident and/or their representative, and (3) an informed consent was obtained prior to device installation to ensure the device was and remained safe and appropriate to use for 3 of 4 sampled residents (Residents 40, 28, & 51) reviewed for accident hazards. This failure placed residents at risk for harm and significant injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 2 of 25 medications for 2 of 6 residents (Resident 70 & 9) observed during medication pass resulted in a medication error rate of 8%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered (PO) medication.

Inspectors wroteBased on observation and record review, the facility failed to ensure residents were provided the correct meal portion size by dietary staff as part of the prescribed therapeutic diet for 1 of 4 residents (Residents 7) reviewed for food concerns and 1 additional sample resident (Resident 1) identified during meal service observation. Failure to ensure residents were provided food as ordered in their diet placed residents at risk for nutritional compromise and related negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were complete, accurate, and readily accessible for 2 of 18 sampled residents (Resident 1& 21) whose records were reviewed. The facility failed to ensure current legal guardianship documents were accurate, accessible to staff, and in resident records. These failures placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent placing residents at risk for facility acquired infections. The facility staff failed to consistently perform Hand Hygiene (HH) before and after resident care/contact. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared, and served in a sanitary manner and in accordance with professional standards of food safety. The failure to ensure food was stored appropriately, the dishwasher reached the required temperature necessary to sanitize dishes, ensure the clean area of the dishwashing area was free of food debris, hand hygiene was performed as required, and food preparation surfaces were free of contaminants left residents at risk of food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement, monitor, and maintain their infection control practices providing a safe and sanitary environment to help prevent the transmission of communicable disease. The failure to ensure staff performed hand hygiene when required, implemented correct Transmission Based Precautions (TBP) for a contagious infection for 1 of 2 residents (Resident 280) reviewed for TBP, ensured staff received education and proper fit testing for N95 respirators, used standard infection control practices during medication pass (Resident 14 and 288) placed residents, staff, and visitors at risk for development of contagious communicable infections and disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing, pneumonia, hospitalization, and even death) staff testing procedures were conducted in a manner consistent with current standards of practice for COVID-19 testing, followed proper infection control guidance for safe testing, and was performed according to the Named brand COVID-19 Point-of-Care manufacturers recommendations to ensure accurate test results. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system to ensure residents were offered assistance to formulate an Advance Directive (AD) for 5 of 18 sampled residents (Resident 9, 34, 15, 20 & 25) who did not have one. The facility failed to obtain the AD from residents who had one and make the documentation readily available in the record for 12 of 18 residents (Resident 9, 34, 15, 20, 21, 43, 12, 25, 17, 63, 225 & 50). Failure to help formulate an AD, document in the medical record that assistance was offered, and have existing AD accessible to facility staff placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure for 4 of 5 staff (Staff FF, GG, II & JJ) reviewed. The facility failed to conduct a criminal background check and/or re-check for 2 of 5 staff (Staff FF & GG) and failed to obtain reference checks for 4 of 5 staff (Staff FF, GG, II & JJ) that placed residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident Care Plans (CP) were reviewed and revised to accurately reflect residents' care needs for 4 of 18 sampled residents (Resident 9, 6, 17, & 25) and failed to timely conduct a CP conference for 2 of 18 residents (Resident 50 & 63) whose CPs were reviewed. These failures placed residents at risk for unmet care needs, diminished quality of life, and deprived residents and their representatives the opportunity to participate in the care and discharge planning process.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their policy and procedures to ensure residents were assessed to be safe to use side rails (SR) or assist bars (AB) and ABs and SRs were installed correctly for 9 of 18 sampled residents (Resident 284, 275, 21, 12, 63, 9, 34, 20, 17 & 25) who had bed rails (BRs - SRs or ABs). Facility failure to attempt alternatives before implementing SRs, identify the necessity for SRs, assess the safety of SRs, and provide informed consent prior to use of SRs placed the residents at risk for harm or significant personal injury up to and including potential for death due to strangulation. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of a resident's discharge or death, for 1 of 1 (Resident 229) discharged residents reviewed. This failure caused a delay in reconciling resident accounts within 30 days as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 8 residents who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account.

Inspectors wroteBased on interview and record review, the facility failed to provide the required liability notice for a sample of 2 of 4 residents (Resident 53 & 39) reviewed for liability notices, who remained in the facility after skilled services ended. This failure placed the residents at risk of not being fully informed of the cost of continued services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place by which the Office of the State Long-Term Care Ombuds (LTCO) received required notification of emergent resident discharges for 3 of 5 residents (Resident 9, 34 & 63) reviewed for discharge to the hospital. Failure to ensure required notifications were completed prevented the Ombud's office the opportunity to educate residents and advocate for them through the discharge process.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a Significant Change in Status Assessment (SCSA) including Care Area Assessments (CAAs) within 14 days after the significant change was identified (or should have been identified) for 2 of 2 residents (Resident 284 & 21) reviewed for significant changes from baseline status and or/function and a terminal prognosis with subsequent hospice services. These failures placed the residents at risk for unmet care needs, diminished quality of life, and quality of care.

Inspectors wroteResident 284 A 10/14/2022 admission MDS showed Resident 284 had moderate to severe cognitive impairment. The resident had depressed mood (felt down/hopeless). Resident 284 weighed 116 pounds and was 61 inches tall (5-foot 1 inch). The resident was assessed to have occasional pain. A 12/05/2022 provider progress note showed Resident 284 was evaluated for continued foot pain and was prescribed routine and as needed pain medications. Review of a 12/06/2022 Physical Therapy (PT) evaluation showed Resident 284 was referred to PT after hospitalization for change in alertness, cognition, functional mobility, low activity tolerance, and unsafe ambulation related to multiple severe infections and malignant cancer. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan, to address pain and discomfort, respiratory compromise after hospitalization, and nutritional status risks for 3 of 18 sample residents (Resident's 50, 63 & 284) reviewed for comprehensive Care Plans (CP). These failures placed the residents at risk for medical complications, unmet care needs, continued decline of nutritional status, and diminished quality of life/quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing services were provided within professional standards of nursing for 9 of 18 residents (Resident 17, 9, 25, 21, 6, 50, 12, 34 & 9) reviewed. Facility failure to ensure: Physician's Orders (POs) were followed (Resident 17) and clarified (Residents 9, 17, & 25); POs were obtained prior to treatment (Resident 21); staff only signed for tasks they completed (Resident 6); POs included an associated diagnosis (Residents 34, 9 & 12); the physician was notified when required (Resident 50), placed residents at risk for medication and treatment errors and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a system to timely, accurately, and consistently: assess nutritional status; identify, implement, monitor, and modify personalized nutritional interventions that met the resident's needs, choices, and cultural preferences to prevent avoidable significant weight loss for 1 of 1 Resident (Resident 284) who experienced a significant weight loss; and failed to ensure residents consistently received the nutritional supplements they were assessed to require to help prevent weight loss for 2 of 6 Residents (Resident 284 & Resident 225) reviewed for nutrition. These failures placed the residents at risk for worsened nutritional status, continued weight loss, and diminished quality of life/quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure artificial nutrition was provided as ordered for residents requiring artificial nutrition, for 2 of 2 residents (Residents 34 & 12) reviewed for enteral tube feeding (nutrition provided via a tube directly to the digestive system). Failure to ensure artificial nutrition was provided as ordered left residents at risk for weight loss, malnutrition, dehydration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to recognize and treat 1 of 4 residents (Resident 50) who were reviewed for pain management. Failure to assess and implement interventions to relieve pain, including physician notification for newly identified pain, resulted in Resident 50 experiencing episodes of untreated pain, and placed the resident at risk for a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 2 of 4 nurses (Staff K and Staff MM) to properly administer 3 of 26 medications for 2 of 6 residents (Resident 288 & 16) observed during medication pass resulted in a medication error rate of 11.54%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their COVID-19 Vaccination Policy and Procedures. The failure to ensure 3 of 3 (Staff AA (Activity Assistant), Staff BB (Certified Nursing Assistant), & Staff OO(Certified Nursing Assistant)) unvaccinated staff implemented the additional precautions the facility would follow to prevent the transmission of COVID-19 placed residents, visitors, and staff at risk for contracting a highly transmissible, communicable disease.