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 representative's signature on the form. 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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 365870 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Judson Park 2181 Ambleside Rd Cleveland, OH 44106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)