Gardens of Mayfield Village: Privacy Violation - OH
That is what a state inspector saw at Gardens of Mayfield Village on the morning of June 25, 2024.
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See the Derila PillowThe resident, identified in inspection records as Resident 33, lives on the facility's behavior unit. Her diagnoses include epilepsy and panic disorder, and she requires assistance with personal care. Her admission assessment documented severe cognitive deficits. She cannot be understood or respond to others. She is frequently incontinent of both bladder and bowel.
Her care plan, dated June 10, 2024, specified that she required one staff member to assist with toileting.
At 7:10 a.m., an inspector walking the behavior unit hallway observed Resident 33 in her bed, receiving incontinence care. The door was open. Her buttocks were exposed.
Ten minutes later, a State Tested Nursing Assistant, identified as STNA 202, confirmed it. Incontinence care had been provided with the door open. That was the interview, in its entirety. No explanation. No dispute.
The facility's own written policy, in place since August 2009, said staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care. A separate subsection of the same policy prohibited demeaning practices and standards of care that compromise dignity.
Gardens of Mayfield Village wrote the rule. A staff member broke it in front of an open door, in a hallway, at seven in the morning, in front of a woman who could not protest and could not ask for help.
The inspection was triggered by a complaint, filed under complaint number OH001545957. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted the violation affected few residents. Those classifications exist on a spectrum that runs from no harm to immediate jeopardy, and this finding sits near the lower end. But the classification reflects regulatory severity, not the experience of the person in the bed.
Resident 33 has epilepsy. She has panic disorder. She cannot speak. She cannot tell anyone what she felt or whether she knew what was happening around her. The inspection record does not tell us whether she was aware of the open door, whether she heard voices in the hallway, or whether anyone noticed her in passing.
What the record does tell us is that the nursing assistant who provided her care did not close the door. And that when asked about it ten minutes later, the nursing assistant confirmed it without apparent confusion about what had occurred.
The facility's policy, written fifteen years before this inspection, anticipated exactly this situation. Subsection ten covered bodily privacy during personal care. Subsection eleven covered demeaning practices. The prohibition was not ambiguous.
The Gardens of Mayfield Village is located at 6757 Mayfield Road in Mayfield Heights. The inspection was completed July 2, 2024. CMS printed the statement of deficiencies on August 8, 2026.
For a woman who cannot respond, cannot report, and cannot close her own door, the policy on the shelf and the morning on the behavior unit hallway were two entirely different things.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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 is what a state inspector saw at Gardens of Mayfield Village on the morning of June 25, 2024.
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.