Health inspection·December 5, 2019

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 record review and interview the facility failed to ensure advance directives for Resident #64 were accurately and consistently noted throughout the resident's medical record. This affected one resident (#64) of one resident reviewed for advance directives. Findings include: Review of the medical record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), morbid obesity, acute respiratory failure with hypoxia, and obstructive sleep apnea. Review of Resident #64's electronic physician's orders, dated 09/25/19 revealed an advance directive for Do Not Resuscitate Comfort Care- Arrest (DNRCC-Arrest), resuscitative therapies before an arrest, but not during or after an arrest. Review of the hard copy of medical record for Resident #64 revealed a signed advance directive for Do Not Resuscitate Comfort Care (DNRCC), care that eases pain and suffering but no resuscitative therapies. Interview on 12/03/19 at 8:52 A.M. with Unit Manager (UM) #400 confirmed a DNRCC-Arrest order was noted in the electronic record and a DNRCC directive was noted in the hard copy of the medical record. Follow up interview on 12/03/19 at 11:24 A.M. with UM #400 revealed Resident #64's desired advance directive was DNRCC-Arrest, and the social worker marked the wrong box on the advance directive in the hard chart. Interview on 12/04/19 at 4:03 P.M. with Licensed Practical Nurse (LPN) #401 revealed if she was unaware of a residents code status she could look for advance directives/code status under the patients name in the electronic medical record, and also in a sleeve in the front of the hard copy of the chart. 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 3 Event ID: 365883 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 365883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Augustine Manor 7801 Detroit Ave Cleveland, OH 44102 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)