Gardens Of Mayfield Village
GARDENS OF MAYFIELD VILLAGE in MAYFIELD HEIGHTS, OH — inspection on July 2, 2024.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the care plan dated 06/10/24 revealed Resident #33 had a self-care deficit with toileting assistance of one required.
On 06/25/24 at 7:10 A.M. observation of the behavior unit hall revealed Resident #33 receiving incontinence care while lying in bed.
The door was open, and Resident #33's buttocks were exposed.
On 06/25/24 at 7:20 A.M. an interview with STNA #202 verified incontinence care was rendered for Resident #33 with the door open.
A review of the policy titled, Quality of life-Dignity, dated August 2009, revealed in subsection ten that staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care.
The policy also stated in subsection 11 that demeaning practices and standards of care that compromise dignity were prohibited.
Also included in point (b), staff to promptly respond to the resident's request for toileting assistance.
This deficiency represents non-compliance investigated under Complaint Number OH001545957.
365355 07/02/2024
Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #48 was cognitively intact.
Review of the care plan dated 06/11/22 revealed Resident #48 had a self-care deficit and needed toileting assistance.
On 06/24/24 at 3:10 P.M. an observation revealed Resident #48 activated the call system.
On 06/24/24 at 3:16 P.M. an observation of Resident #48 revealed the call light being answered by State Tested Nurse Aide (STNA) #269. Resident #48 told STNA #269 that they needed changed. STNA #269 left the room of Resident #48 without rendering care.
On 06/24/24 at 3:25 P.M. an interview with Resident #48 verified STNA #269 did not render care. Resident #48 stated they needed changed. Resident #48 stated sometimes takes a half hour for call light response.
On 06/24/24 at 3:40 P.M. an observation revealed Resident #48 activated the call system.
The call light was answered immediately by the Regional Licensed Nursing Home Administrator (LNHA) #311.
The call system was left activated. An interview at time of the observation with LNHA #311 revealed call lights are to remain activated until care is rendered. LNHA #311 stated she was going to get an STNA to render care.
On 06/24/24 at 3:50 P.M. the call light for Resident #48 was answered by STNA #235.
The door was closed, and care was rendered.
A review of the policy titled, Answering the Call Light, dated October 2010, revealed the purpose of the policy is to respond to a resident's requests and needs.
The policy also stated to do what the resident needs and if you cannot fulfill the resident request, ask the nurse supervisor for assistance.
The policy further stated if you promised a resident you will return, do so promptly.
This deficiency represents non-compliance investigated under Complaint Numbers OH 00154597 and OH00154554 and OH00154554 and is an example of continued noncompliance to the survey completed on 06/05/24.
365355 07/02/2024
Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124
Doctor #315 were notified of Resident #27's weight loss.
A review of the policy titled, Weight Assessment and Intervention, dated September 2008, revealed
• Under the section titled weight assessment, subsection one, nursing staff would measure resident weights on admission, the next day, and weekly for two weeks. • Under the section titled weight assessment, subsection three, any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.
When the weight was verified, nursing would immediately notify the dietician. • Under the section titled weight assessment, subsection six, the threshold for significant unplanned and undesired weight loss at six months was severe if it was greater then 10%. • Under the section titled care planning subsection one care planning for weight loss or impaired nutrition would be a multidisciplinary effort and would iclude the physician, nursing staff, the dietician, the consultant pharmacist and the resident or the resident's legal surrogate.
This deficiency represents non-compliance investigated under Complaint Number OH00154554.
365355 07/02/2024
Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124
an hour late resulting in the lunches for the day being served late.
minimal harm A review of the document titled; Meal Service Times that was undated revealed lunch service times as follows:
• First Floor Dining room [ROOM NUMBER]:00 P.M. • First Floor Blue Hall 12:15 P.M. • Second Floor Blue Hall 12:30 P.M. • Second Floor [NAME] Hall 12:45 P.M. • Second Floor Yellow Hall 1:00 P.M. • Second Floor Red Hall 1:15 P.M.
This deficiency represents non-compliance investigated under Complaint Number OH00154520.
365355 07/02/2024
Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124
Review of CMS's QSO-24-08-NH dated 03/20/24 pertaining to Enhanced Barrier Precautions in Nursing Homes revealed CMS was issuing new guidance for State survey agencies and long-term care facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. EBP recommendations now included use of EBP's for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multi-drug resistant organism status.
The new guidance related to EBP's was being incorporated into F-F880 Infection Prevention and Control.
Guidance under F-F880 indicated EBP's referred to an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP's were to be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing.
A review of the policy titled; Enhanced Barrier Precautions Policy and Procedure, dated 04/01/24, revealed EBP is indicated for wounds and indwelling medical devices.
The policy stated to use gowns and gloves for high contact resident care activities.
The policy also stated follow EBP with device use.
This deficiency represents an incidental finding identified during the complaint investigation and is an example of continued noncompliance to the survey completed on 04/04/24.
365355 07/02/2024
Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124
point (a) the policy stated characteristics of a homelike setting include a clean, sanitary, and orderly
This deficiency represents noncompliance investigated under Complaint Number OH00154957 and is an example of continued noncompliance to the survey completed on 05/09/24.
F-F880 indicated EBP's referred to an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP's were to be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing.
A review of the policy titled; Enhanced Barrier Precautions Policy and Procedure, dated 04/01/24, revealed EBP is indicated for wounds and indwelling medical devices.
The policy stated to use gowns and gloves for high contact resident care activities.
The policy also stated follow EBP with device use.
365355
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 365355 B.
Wing 07/02/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.