JUDSON PARK
CMS
Actual Harm
Documentation Failure
Medication Error
Penalty
$25,847
Outcome
JUDSON PARK in CLEVELAND, OH was fined $25,847 by CMS following 10 deficiency citations identified during federal surveys.
Details
JUDSON PARK (CLEVELAND, OH) — $25,847 in CMS Fines
Outcome: JUDSON PARK in CLEVELAND, OH was fined $25,847 by CMS following 10 deficiency citations identified during federal surveys.
Deficiency areas cited:
- Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- Develop and implement policies and procedures for flu and pneumonia vaccinations.
- Make sure that a working call system is available in each resident's bathroom and bathing area.
- Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
- Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
How Crucible Prevents This
Crucible's continuous compliance monitoring would have flagged the regulatory gaps that led to these CMS fines — through automated survey-readiness checks, real-time deficiency tracking, staff compliance dashboards, and corrective action plan enforcement — preventing the violations before the next federal survey.
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