Health inspection·May 9, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Interview on 05/08/24 at 2:55 P.M. with Director of Therapy (DT) #167 revealed Resident #9 had a therapy goal to strengthen the paraplegia leg muscles. Resident #9 required assistance with rolling and positioning in bed. On the initial assessment, completed 04/19/24, the physical therapist entered an order for bed rails and a trapeze bar to assist Resident #9 with bed mobility. DT #167 verified the bed rails and trapeze bar were not implemented. Residents Affected - Few Interview on 05/08/24 at 3:10 P.M. with the Administrator revealed Resident #9 was offered an extender to the foot of the bed, however the resident did not like it and it was removed. The Administrator stated she would rent an appropriate bed with rails and a trapeze. 2. Review of the medical record for Resident #19 revealed an admission date of 01/23/24. Diagnoses included morbid obesity, chronic obstructive pulmonary disease (COPD) and type II diabetes. Review of the quarterly MDS assessment, dated 05/01/24, revealed Resident #19 had intact cognition and was dependent on staff for rolling left to right, toileting, and transferring. Review of the Care Plan, dated 05/07/24, revealed Resident #19 had a self-care deficit related to immobility. Interventions included a mechanical lift with two staff assistance with all transfers. Interview on 05/09/24 at 7:56 A.M. with Resident #19 revealed on 05/06/24 she did not get transferred back to bed until after midnight. Resident #19 stated she usually went to bed around 10:00 P.M. but the mechanical lifts required charging and it took a couple of extra hours for one to be available to transfer her. 3. Review of the medical record for Resident #58 revealed an admission date of 08/30/18. Diagnoses included morbid obesity, multiple sclerosis (MS), and heart failure. Review of the quarterly MDS assessment, dated 04/16/24, revealed Resident #58 had intact cognition and was dependent on staff for rolling left to right, toileting, and transferring. Review of the Care Plan, dated 04/22/24, revealed Resident #58 had a self-care deficit related to MS and chronic pain. Interventions included a mechanical lift with two staff assistance with all transfers. Review of an ambulance run report, dated 05/06/24 at 11:48 P.M., revealed the facility requested a squad to assist three bariatric patients, Residents #9, #19, and #58, with transfers into bed. Interview on 05/08/24 at 10:55 A.M. with Assistant Fire Chief (AFC) #191 with the local fire department revealed a call was received on 05/06/24 around midnight from the facility asking for help to get three bariatric residents back into bed. The request was refused due to being a non-emergency situation. Interview on 05/08/24 at 12:04 P.M. with State Tested Nursing Assistant (STNA) #118 revealed on 05/06/24 at 7:00 P.M. she arrived on the unit and Residents #9 and #19 were requesting to be transferred back to bed. STNA #118 stated the mechanical lift used for bariatric residents was charging. There was another lift, however she did not feel safe transferring the residents with that lift. STNA #118 left at 11:00 P.M. and informed Residents #9 and #19 the lift was still charging. STNA #118 confirmed Residents #9 and #19 could not be transferred to bed as requested due to mechanical lifts not being charged and available for safe transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Interview on 05/08/24 at 12:29 P.M. with STNA #177 revealed on 05/07/24 at 12:00 A.M. he arrived on the unit. Residents #9, #19 and #58 were up and needed to be transferred to bed. One lift was plugged in charging but there was a functional lift available at that time. All three residents were transferred back to bed with the available lift. STNA #177 stated they used five staff to transfer the residents back to bed due to their size and to ensure their safety. Residents Affected - Few Interview on 05/08/24 at 12:44 P.M. with Registered Nurse (RN) #155 confirmed Residents #9, #19 and #58 requested to be transferred to bed but the mechanical lift was not charged. RN #155 stated she called the fire department requesting their assistance, but they refused. Interview on 05/09/24 at 8:09 A.M. with Resident #58 revealed on 05/06/24 at 8:00 P.M., she requested to go to bed. The STNA told her the lift was not charged. Resident #58 stated five staff members transferred her to bed using a mechanical lift around 1:00 A.M. Interview on 05/09/24 at 9:30 A.M. with Maintenance Director (MD) #143 revealed on 05/06/24 at 7:00 P.M. he was called back to the facility due to two mechanical lifts not functioning. The battery pack from one lift was not correctly put on the charger and the other lift had a battery requiring a new charging cord. The charging cord had a bent adapter, causing it not to charge. MD #143 stated he fixed the charging cord and both lifts were charged and operational by 11:30 P.M. This deficiency represents non-compliance investigated under Complaint Numbers OH00153513 and OH00153399 and OH00153402 and is an example of continued noncompliance from the survey dated 04/04/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on medical record review, observation, staff interview, review of mechanical lift manufacturer's instruction and review of facility policy, the facility failed to ensure staff were properly trained to safely transfer residents utilizing mechanical lifts. This affected one (#58) of three residents reviewed for transfers. The facility identified 13 residents requiring a mechanical lift for transfer. The facility census was 64. Finding include: Review of the medical record for Resident #58 revealed an admission date of 08/30/18. Diagnoses included morbid obesity, multiple sclerosis (MS) and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/16/24, revealed Resident #58 had intact cognition and was dependent on staff for rolling left to right, toileting, and transferring. Review of the Care Plan, dated 04/22/24, revealed Resident #58 had a self-care deficit related to MS and chronic pain. Interventions included a mechanical lift with two staff assistance with all transfers. Observation on 05/08/24 at 5:00 P.M. of the second-floor nurses' station revealed and new bariatric mechanical left that stated for use up to 1000 pounds. Observation on 05/09/24 at 10:05 A.M. of a mechanical lift transfer with State Tested Nurses Aide (STNA) #113 and the Director of Nursing (DON) for Resident #58 revealed the staff utilized the new bariatric mechanical lift. Continued observation revealed STNA #113 and the DON placed a lifting pad under the resident. STNA #113 brought the lift into the room and struggled to position the base of the lift under the bed due to the long length of the legs on the base. The DON explained in order to connect the lifting pad, which held Resident #58, the legs to the base must be fully opened in width and fully extended length wise. The DON pressed a button and the legs on the base of the lift began to fully open in width and the legs extended an additional four feet in length. The lift pad was connected to the lift and STNA #113 started to move the lift and the resident. Due to the legs being extended, there was no room for the lift to move and became stuck with Resident #58 suspended. The DON pushed the bed out of the way to free the legs of the lift. The lift needed to exit through the door into the hallway where Resident #58's wheelchair was located, however; the lift would not fit through the door with the legs extended. The DON tried to close the legs of the lift, but due to the resident being suspended in a high position, it was not possible to close the legs. The DON lowered the resident to approximately a half inch off the floor and closed the legs of the lift. The DON called for Licensed Practical Nurse (LPN) #122 from the hallway to assist with maneuvering the lift. The DON grabbed the resident's lift pad to ensure the resident did not scrape across the ground while STNA #113 and LPN #122 struggled to push and maneuver the lift about 10 feet into the hallway. Once in the hallway the resident was lifted from the floor and positioned over the wheelchair. Resident #58 was lowered into the wheelchair and disconnected from the lift. The observation lasted for 40 minutes from the beginning of the transfer until Resident #58 was transferred into the wheelchair. Interview on 05/09/24 at 10:48 A.M. with STNA #113 confirmed she had not been trained on how to use the new lift and stated she did not think it went bad for the first time she used it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/09/24 at 10:50 A.M. with LPN #122 verified the transfer using the new mechanical lift was unsafe for Resident #58 due to the resident being close to the ground. LPN #122 confirmed she never received training on the new lift and during the transfer her legs were injured on the extended legs of the base. Interview on 05/09/24 at 11:30 A.M. with the DON revealed she had not previously used the lift utilized to transfer Resident #58 and it was more complicated than the other facility lifts. The DON confirmed the transfer did not go well and was unsafe for Resident #58. While the DON stated she provided verbal training from the lift manual to staff, there was no evidence of the training. The DON stated going forward, all staff would receive training and perform a competency test. Interview on 05/09/24 at 12:02 P.M. with Registered Nurse (RN) #166 revealed she was not trained on the new mechanical lift, which was on the floor and available for staff use with transfers. Interview on 05/09/24 at 12:15 P.M. with STNA #140 revealed she never received training on the new mechanical lift, which was available for use with transfers. Review of the Invacare Reliant manufacture instructions revealed not to attempt any transfer without thoroughly reading the instructions in the user manual, observe a trained team of experts perform the lifting procedures, and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. Review of the facility policy titled Lifting Machine, Using a Mechaical, revised July 2017, revealed lift design and operation vary across manufactures. Staff must be trained and demonstrate competency using the specific machine or device utilized in the facility. This deficiency represents non-compliance investigated under Complaint Number OH00153402 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, medical record review and review of work orders, the facility failed to ensure the environment was adequately maintained. This affected three (#49, #55 and #58) of five residents reviewed for environmental concerns. The facility census was 64. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of 05/26/22. Diagnoses included dementia, malnutrition, anxiety and adult failure to thrive. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/09/24, revealed the resident was severely cognitively impaired. She was totally dependent upon staff for eating, oral hygiene, personal hygiene, showering and dressing. Observation on 05/08/24 at 9:08 A.M. revealed the window ledge in Resident #49's room had wallpaper located directly underneath it, which was peeling from the wall. There was an unknown black substance on the back of the wallpaper. The wall behind the wallpaper was cracked and falling off in pieces to the floor beneath. Concurrent interview with Maintenance Director (MD) #143 confirmed the observation. He revealed the black substance on the back of the wallpaper was mildew. He stated the facility was in the process of removing all wallpaper from the facility. MD #143 denied any specific knowledge of the wall paper peeling in Resident #49 's room or the wall behind it breaking off in pieces. Review of a work order dated 04/02/24 revealed the wallpaper under the window in Resident #49's room was peeling. 2. Review of the medical record for resident #55 revealed an admission date of 07/07/22. Diagnoses included diabetes, heart disease, kidney disease, anxiety and altered mental status. Review of the quarterly MDS assessment, dated 04/02/24, revealed the resident was cognitively intact. Resident #55 required set up or clean up assistance with eating and oral hygiene and was dependent for toileting, showering, dressing and hygiene. Review of the medical record for resident #58 revealed an admission date of 03/17/16. Diagnoses included morbid obesity, muscle weakness. heart disease and lymphedema. Review of the comprehensive MDS assessment, dated 04/16/24, revealed the resident was cognitively intact. Resident #58 required supervision or touch assistance with eating, set up or clean up assistance with oral hygiene and was dependent for toileting, showering, dressing and hygiene. Observation on 05/08/24 at 9:12 A.M. of the shared room for Residents #55 and #58 revealed the window was cracked and covered with adhesive tape. Concurrent interview at the time of the observation with MD #143 confirmed the observation. MD #143 denied knowledge of the cracked window. This deficiency represents non-compliance investigated under Complaint Number OH00153513. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 6 of 6