Gardens of Mayfield Village: Call Light Failures - OH
That happened at Gardens of Mayfield Village on the afternoon of June 24, 2024, and it took another 34 minutes before anyone came back to help.
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See the Derila PillowThe resident at the center of the complaint, identified in inspection records only as Resident #48, had been living at the facility since February 2024. The person had type II diabetes, a chronic ulcer on the left foot, and a documented need for toileting assistance. Cognitively, inspectors noted, the resident was fully intact, meaning they understood exactly what was happening and could describe it clearly.
At 3:10 p.m., Resident #48 activated the call light. Six minutes later, State Tested Nurse Aide #269 answered it. The resident said they needed to be changed. STNA #269 left.
At 3:25 p.m., an inspector interviewed Resident #48, who confirmed the aide had not returned and had not rendered any care. The resident said they still needed to be changed. Then, without apparent irony, the resident added that sometimes it takes a half hour just to get a response to the call light in the first place.
At 3:40 p.m., Resident #48 activated the call light again. This time it was answered immediately, but not by a nurse aide. The Regional Licensed Nursing Home Administrator, identified as LNHA #311, responded to the call. She told the inspector that call lights are supposed to stay activated until care is actually delivered. She said she was going to find an aide to come help.
The call light stayed on.
At 3:50 p.m., a different aide, STNA #235, finally came to the room. The door was closed. Care was rendered. Forty minutes had passed since Resident #48 first asked for help.
The facility's own call light policy, written in October 2010, says staff should do what the resident needs, and if they cannot, they should ask a nurse supervisor for assistance. It also says that if a staff member promises to return, they should do so promptly. STNA #269 did not ask a supervisor. There is no indication in the inspection record that the aide told the resident they would be back.
What makes this inspection notable is not just what happened on June 24. The report identifies this as continued noncompliance, tied to a prior survey completed less than three weeks earlier, on June 5, 2024. The same problem, apparently, had already been documented. Inspectors returned and found it happening again. The deficiency was investigated under two separate complaint numbers filed against the facility.
The administrator who answered the call light that afternoon was the regional administrator, not a floor supervisor or a charge nurse. Her presence during the inspection, and her explanation of what the call light policy requires, did not prevent the resident from sitting and waiting while the system she described went unenforced around her.
Resident #48 had a wound on their left foot. They had diabetes. They needed help with toileting and had a care plan that said so. When they asked for that help, the first person who came listened and left. The second person to respond was an administrator who went to find someone else. The third person, finally, closed the door and helped.
By then it was 3:50 in the afternoon, and Resident #48 had been waiting since 3:10.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens of Mayfield Village from 2024-07-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 14, 2026 · Our methodology
GARDENS OF MAYFIELD VILLAGE in MAYFIELD HEIGHTS, OH was cited for violations during a health inspection on July 2, 2024.
That happened at Gardens of Mayfield Village on the afternoon of June 24, 2024, and it took another 34 minutes before anyone came back to help.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.