Gardens Of Mayfield Village

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 365355 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0880 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. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 365355 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 48565

Residents Affected - Many Based on record review, observation, interview and facility policy review, the facility failed to provide clean shower rooms for resident use. This had the potential to affect all residents. The facility also failed to provide

a clean privacy curtain for two residents (#11 and #12) of 74 residents reviewed for environment. The facility census was 74.

Findings include:

On 06/24/24 at 9:30 A.M. during the facility tour, an observation of the resident shower room on the 100 hall was noted to have a sink with buildup of dirt. The floor had a buildup dirt and debris on it. The tiles were cracked and broken in the corner of the shower. There was what appeared to be smeared bowel movement

on the toilet seat. Maintenance Director (MD)#259 verified the findings at the time of the tour.

On 06/24/24 at 9:50 A.M. an observation of the shower room on the second-floor blue hall was noted to have

a dirty sink. The sink was dry and appeared to not have been used recently. The shower was noted to have

a black substance on the tiles. The floor had a buildup dirt and debris. The shower chair in the shower had what appeared to be dried bowel movement on it. The floor in the shower room was dry and appeared not to have been used recently. MD #259 verified the findings at the time of the observation.

On 06/24/24 at 10:00 A.M. an observation of the second-floor locked unit shower room revealed a dirty sink.

The sink was dry and appeared to not have been used recently. The floor was noted to have a buildup dirt and debris. The floor in the shower room was dry and appeared not to have been used recently. MD #259 verified the findings at the time of the observation.

On 06/24/24 at 10:10 A.M. an observation of the shower room on the second-floor red hall revealed a dirty sink. The sink was dry and appeared not to have been used recently. The floor was noted to have a buildup dirt and debris. The floor in the shower room was dry and appeared not to have been used recently. MD #259 verified the findings at the time of the observation.

On 06/24/24 at 10:30 A.M. an interview with Housekeeping and Laundry Manager #253 revealed shower rooms were to be cleaned after each use and daily by the housekeeping department.

On 06/25/24 at 8:15 A.M. an observation of Residents #11 and #12's room revealed a privacy curtain hanging between the two beds. The curtain was partially draped over a portable toilet that was next to Resident #11 bed. The curtain had a large brown smear on it. An interview with Resident #12 at the time of

the observation revealed they thought Resident #11 had an accident.

On 06/25/24 at 8:20 A.M. MD #259 verified the brown smear on the curtain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 365355 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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)

F 0921 A review of the policy titled Shower/Tub Bath, dated October 2010, revealed in the section titled Steps in the Procedure point #9, Be sure the tub or shower is clean. If the tub or shower is not clean, clean it with the Level of Harm - Minimal harm or approved disinfectant. Point #29 under the same subsection stated to clean the bath. potential for actual harm

A review of the undated policy titled Housekeeping Guidelines revealed in point #8 the procedure for Residents Affected - Many cleaning the bathroom. The policy stated to clean counter, sink, mirror, the entire toilet, walls, if necessary, then mop the floor.

A review of the policy titled Quality of Life-Homelike Environment, dated May 2017, revealed, Residents are provided with a safe, clean, comfortable and homelike environment. In subsection 2, point (a) the policy stated characteristics of a homelike setting include a clean, sanitary, and orderly environment.

This deficiency represents noncompliance investigated under Complaint Number OH00154957 and is an example of continued noncompliance to the survey completed on 05/09/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 365355