Health inspection·January 24, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **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 drawn across the form and through the date and the word full written in large letters next to the words DNR comfort care. There was no patient nor authorized Interview on [DATE] at 2:05 P.M. with Director of Nursing (DON) #301 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form was not completed to accurately identified code status and was not signed by Resident #181 or their authorized representative. DON #301 revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 2:07 P.M. Registered Nurse (RN) #304 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not properly completed. RN #304 revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 3:36 P.M. with [NAME] President of Health Services (VPHS) #300 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not properly completed. VPHS #300 revealed the code status was supposed to be in the orders and in the hard medical chart. 2 Review of Resident #184's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cellulitis of right lower limb, edema, hypertension, acute kidney failure Page 1 of 7 365870 365870 01/24/2023 Judson Park 2181 Ambleside Rd Cleveland, OH 44106

F 0578 with tubular necrosis, and obstructive sleep apnea. Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders for Resident #184 revealed there was no order for code status in the electronic medical record (EMR) or in the hard medical chart. Residents Affected - Few Review of the facility document titled DNR Order Form, dated [DATE] and having Resident #184's name on it, revealed a physician signature, a large line drawn across the form and through the date and the word full written in large letters next to the words DNR comfort care. There was no patient nor authorized Interview on [DATE] at 2:05 P.M. with the DON confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not properly completed, crossed out, and on top written Full. The DON revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 2:07 P.M. RN #304 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC for not completed correctly, crossed out, and on top written Full. RN #304 revealed the code status was supposed to be in the orders and in the hard medical chart. Interview on [DATE] at 3:36 P.M. with VPHS #300 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC for not completed correctly, crossed out, and on top written Full. VPHS #300 revealed the code status was supposed to be in the orders and in the hard medical chart. 3 Review of Resident #186's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute kidney failure with tubular necrosis, alcohol dependence, and epilepsy. Review of the physician's orders for Resident #186 revealed there was no order for 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 #186's name on form. The form did not specify what the resident's code status was in the event of cardiac or respiratory arrest. Interview on [DATE] at 2:05 P.M. with the DON confirmed there was no code status in the orders and in the hard medical chart was a DNR CC for not completed. DON revealed the code status is supposed to be in the orders and in the hard medical chart correctly. Interview on [DATE] at 2:07 P.M. RN #304 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not completed. RN #304 revealed the code status is supposed to be in the orders and in the hard medical chart correctly. Interview on [DATE] at 3:36 P.M. with VPHS #300 confirmed there was no code status in the orders and in the hard medical chart was a DNR CC form not completed. VPHS #300 revealed the code status was supposed to be in the orders and in the hard medical chart correctly. Review of facility policy, Advance Directives/CPR, revised 08/2016, revealed every resident had a 365870 Page 2 of 7 365870 01/24/2023 Judson Park 2181 Ambleside Rd Cleveland, OH 44106

F 0578 right to make an informed decision about their advance directives, physicians would write orders for the advance directives and copies of the advanced directives would be kept in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365870 Page 3 of 7 365870 01/24/2023 Judson Park 2181 Ambleside Rd Cleveland, OH 44106

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 influenza vaccine for 2022. 2. Review of Resident #185's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, atrial fibrillation, depression, and mild cognitive impairment. Review of admission MDS 3.0 assessment dated [DATE] revealed the resident was moderately impaired for decision making and required extensive assistance of one for bed mobility, dressing, toileting, limited assistance of one for transfers, hygiene, and eating supervision with set up help. Review of Resident #185's immunization records revealed he had an influenza vaccine on 11/19/19 prior to his admission on [DATE] and there was no evidence the facility offered an influenza vaccine upon admission. 3 Review of Resident #186's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, acute kidney failure with tubular necrosis, alcohol dependence, epilepsy, and unspecified dementia. Review of Resident #186's immunization records revealed she had an influenza vaccine on 09/20/17 prior to her admission on [DATE] and there was no evidence the facility offered an influenza vaccine upon her admission to the facility. Interview on 01/18/23 at 3:36 P.M. with VPHS #300 verified staff were not offering vaccinations screening accurately upon admission and yearly as required. VPHS #300 was unable to provide any documentation the influenza vaccine was offered to Resident #185 and #186 upon admission nor Resident #17 at least annually. VPHS #300 reported this was an issue at the facility. Review of facility policy, Influenza and Pneumococcal Immunization Program, revised 10/2018, revealed the nurse admitting the resident was responsible for completing Influenza/Pneumococcal Immunization Resident Assessment form to determine which residents needed vaccines and annual flu vaccination education would be provided to the resident or their representative. The flu vaccination would be 365870 Page 4 of 7 365870 01/24/2023 Judson Park 2181 Ambleside Rd Cleveland, OH 44106

F 0883 offered to all residents able to get the vaccine. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365870 Page 5 of 7 365870 01/24/2023 Judson Park 2181 Ambleside Rd Cleveland, OH 44106

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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 be hanging loose from the wall. Pushing the call light button revealed no light or sound went on above the door, in the hall, or at the nursing station to notify staff the call light was used. The resident had no handbell or other alternate means of ringing for assistance. On entry to the room, the door was closed and the television was turned up to a loud volume. Interview with Licensed Practical Nurse (LPN) #501 on 01/17/23 at 10:31 A.M. confirmed the above findings. She said she would call maintenance to address the concern. Observation of Resident #2's room on 01/17/23 at 11:24 A.M. and 1:39 P.M. revealed the call light attachment box was now firmly connected to the wall. However, testing it again revealed there was still no noise or light visible from the alarm lights above the doorway, in the hall, or at the nursing station, and she still did not have any substitute means of summoning assistance. Interview with LPN #501 on 01/17/23 at 1:39 P.M. confirmed the above findings. Observation of Resident #2's room on 01/18/23 at 9:48 A.M. revealed the call light to still not be functional, and she still had no alternate means of ringing for assistance. Interview with State Tested Nursing Aide (STNA) #502 on 01/18/23 at 9:50 A.M. confirmed the above findings. She said the call lights were silent, but were supposed to activate the lights above the doors and in central hallways positions so staff could see someone needed help. They were also supposed to activate STNA pagers. Observation at the time of the above interview revealed Resident #2's call light did not activate STNA #502's pager. Interview with Registered Nurse #503 on 01/18/23 at 9:55 A.M. revealed LPN #501 contacted maintenance regarding the broken call light, who said they would need to send out a service call. She confirmed the facility should have provided the resident a substitute means of calling for help until the problem was addressed. 365870 Page 6 of 7 365870 01/24/2023 Judson Park 2181 Ambleside Rd Cleveland, OH 44106

F 0919 Following surveyor intervention, the facility provided Resident #2 with a handbell on 01/18/23 at 10:00 A.M. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365870 Page 7 of 7