Cycle 1
Health 2023-01-24 · Fire 2023-01-24
3 health deficiencies
Top issue: Environmental (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cleveland, OH
Judson Park
4-star overall rating with 4-star inspections with $25,847 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2181 Ambleside Rd, Cleveland, OH
(216) 721-1234
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-03-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.12
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
4.07
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
7.84
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
5.19
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
5.91
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
7.93
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,793
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9956
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.14
Baseline 19.99% · Performance 20.91% · Measure score 1.14 · Achievement 1.14 · Improvement 0
Healthcare-associated infections
1.66
Baseline 6.02% · Performance 7.34% · Measure score 1.66 · Achievement 1.66 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Baseline 5.34 hours · Performance 6.91 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.09% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 150 · Observed rate 10% · Lower 95% interval 8.03% |
| Discharge to community | 61.96% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 155 · Observed rate 57.42% · Lower 95% interval 55.48% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 1.15% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 87 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 44 · Denominator 66 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 27 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 87 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 6.9% · Lower 95% interval 4.32% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 24.32% |
42%
17.7 pts worse
|
Numerator 9 · Denominator 37 |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 34 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 66.67% |
25.2%
41.5 pts better
|
Numerator 24 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
92.4%
3.6 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
94.5%
1 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
26.1%
21.8 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 12.3% |
6.2%
6.1 pts worse
|
5.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
25.4%
16.8 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
11.5%
0.5 pts worse
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
6.2%
2.4 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
0.5%
3.6 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
21.7%
2.1 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
3.7%
0.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
78.1%
8.4 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 88.4% · Q3 85.9% · Q4 86.1% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
12.5%
6.9 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 6.0% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.2% |
75.6%
9.4 pts worse
|
79.7%
13.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
25.1%
1.6 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 31.3% · Expected 27.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-03-05 · Fire 2020-03-05
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-01-24 · Fire 2019-01-24
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-01-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-02
F · Potential for more than minimal harm
2020-03-05
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2020-04-23
F · Potential for more than minimal harm
2020-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-23
F · Potential for more than minimal harm
2020-03-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-04-23
F · Potential for more than minimal harm
2020-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-23
E · Potential for more than minimal harm
2020-03-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-23
F · Potential for more than minimal harm
2019-01-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-04-15
F · Potential for more than minimal harm
2019-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-15
F · Potential for more than minimal harm
2019-01-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-15
F · Potential for more than minimal harm
2019-01-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-04-15
F · Potential for more than minimal harm
2019-01-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-04-15
C · Minimal harm
2019-01-24
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-03-15
C · Minimal harm
2019-01-24
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-03-15
Inspection history
Recent health citations
G · Actual harm
2024-10-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-01
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-01
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-01
G · Actual harm
2024-03-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-03
D · Potential for more than minimal harm
2023-01-24
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-24
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-24
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-03-02
D · Potential for more than minimal harm
2020-03-05
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-03-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-04-23
Penalties and ownership
What sits behind the stars
$25,847
2024-10-01
Fine
Fine · fine $25,847
Fine
Ownership
Auwerter, Jay
Corporate Director · Individual
Baeslack, William
Corporate Director · Individual
Carnovale, James
Corporate Officer · Individual
Dunn, Cynthia
Corporate Officer · Individual
Hartwell, Sam
Corporate Director · Individual
Judson
Operational/Managerial Control · Organization
Kennedy, Maryellen
W-2 Managing Employee · Individual
Koppelman, Cathy
Corporate Director · Individual
Shaw, Kevin
Corporate Director · Individual
Us Bank National Association
5% Or Greater Mortgage Interest · Organization
Vegh, Amy
Corporate Director · Individual
Nearby options
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#2
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2-star overall rating with 1-star inspections with $8,171 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
The Gardens Of Fairfax Health Care Center
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1-star overall rating with 1-star inspections with $200,208 in total fines with 21 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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