Health inspection·July 2, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. A review of medical records for Resident #33 revealed an admission date of 5/6/24. Significant diagnoses include epilepsy, panic disorder, and a need for assistance with personal care. Review of the admission MDS assessment dated [DATE] revealed Resident #33 had severe cognitive deficit. The resident was unable to be understood or respond. Resident #33 was frequently incontinent of bladder and bowel. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 2 of 12 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 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed respond to Resident #48's needs in a timely manner. This affected one resident (#48) of 74 residents observed for call light response. The facility census was 74. Residents Affected - Few Findings include: A review of medical records for Resident #48 revealed an admission date of 02/16/24. Significant diagnoses included diabetes mellitus type II, need for personal assistance, and a chronic ulcer of other part of the left foot. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 3 of 12 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 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and individualized nutrition program to monitor, ensure nutritional recommendations were implemented and prevent weight loss for Resident #27 who was admitted to the facility with a new gastrostomy tube/enteral feedings. This affected one resident (#27) of five residents who were identified as receiving parenteral nutrition in the facility. The facility census was 74. Residents Affected - Few Actual Harm occurred on 03/01/24 when Resident #27, who received parenteral nutrition (nutrition given via a feeding tube inserted into the abdomen due to an inability to take in adequate nutrients orally) was identified to have a severe weight loss. On 01/26/24 the resident's admission weight was documented to be 145 pounds. On 02/29/24 the resident weighed 139.2 pounds and on 03/01/24 the resident weighed 115.8 pounds reflecting a 23.4 pound/16.8 percent (%) significant weight loss. In addition to a lack of intervention(s) to prevent the weight loss, at the time the weight loss was identified the facility failed to obtain a re-weight, failed to notify the registered dietitian, and failed to notify the physician. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses including alcohol dependence with withdrawal, viral hepatitis B, viral hepatitis C, moderate protein calorie malnutrition and dysphagia (difficulty swallowing). Record review revealed the resident had a gastrostomy tube inserted during the hospitalization prior to his admission and received parenteral nutrition/hydration via the gastrostomy tube. A review of the hospital referral for Resident #27 dated 01/18/24 revealed the resident's weight was 61 kilos and 236 grams (135 pounds). Review of the medical record for Resident #27 revealed an admission weight dated 01/26/24 taken by a mechanical lift scale (a scale used to lift resident to obtain a weight due to inability to stand) was 145 pounds. admission physician orders included an order for the enteral feeding, Isosource 1.5 calorie oral liquid (a nutritional supplement) to be administered via the feeding tube at 50 milliliters (ml) per hour continuously . Resident #27 had an admission diet order to have nothing by mouth. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating mild cognitive impairment. The assessment revealed Resident #27 received 51% or more of his total calories through parenteral or tube feeding means. Review of the admission care plan dated 02/05/24 revealed Resident #27 had potential risk for issues related to nutrition, low body mass index (BMI) and receiving nothing by mouth (NPO) status with a feeding tube. Interventions included providing tube (enteral) feed order as prescribed and monitoring weights (no frequency provided and no physician order for when to obtain weights for the resident). The care plan indicated nursing to notify the physician of any significant changes including a 3% weight change in one week, a 5% or more change in one month, or a 10% or more change in six months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 4 of 12 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 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 0692 Level of Harm - Actual harm Residents Affected - Few An admission nutrition assessment dated [DATE] revealed the resident had a weight of 145 pounds with a body mass index (BMI) of 20 which was considered underweight for advanced age. Registered Dietician /Licensed Dietitian Nutritionist (RD/LDN) #310 recommended to increase the tube feeding for Resident #27 from Isosource 1.5 at 50 ml per hour continuous (1800 calories) via feeding tube to 70 ml per hour continuous (2520 calories) via the feeding tube. Review of the medical record revealed Resident #27's weight on 02/09/24 taken by a wheelchair scale (a scale with a ramp attached in which a person is weighed while seated in a wheelchair) was 141.5 pounds. Review of the medical record revealed Resident #27's weight on 02/29/24 taken by a wheelchair scale was 139.2 pounds. A review of the Medication Administration Record (MAR) for February 2024 revealed Resident #27 received Isosource 1.5 at 50 ml/hour continuously throughout the entire month. Record review revealed the recommendation to increase the Isosource to 70 ml/hour continuous via feeding tube dated 02/05/24 was not completed. Review of the medical record revealed Resident #27's weight on 03/01/24 taken by a sit-down scale (a scale with a chair attached so a person can be seated for their weight due to an inability to stand) was 115.8 pounds. This represented a 16.8% weight loss. There was no documented evidence Resident #27 was reweighed at this time to verify the weight and no documented evidence the dietitian and physician were notified of the weight loss. Review of the medical record revealed Resident #27's weight was obtained on 03/08/24 using a sit-down scale which was 117.6 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. Review of the medical record revealed Resident #27's weight on 03/19/24 taken by a sit-down scale was 116.5pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. A nutrition progress note dated 03/19/24 revealed Resident #27 was reviewed related to a significant weight change and request to change tube feed to nocturnal (nighttime feeding). The weight in the assessment was documented to be 118 pounds with a BMI of 16 (underweight for advanced age). The recommendation by RD/LDN #310 was to provide 240 ml bolus of Isosource 1.5 (1080 calories) and Isosource 1.5 at 80 ml/hour continuous from 6:00 P.M. until 6:00 A.M. (1440 calories) for a total caloric intake of 2520 calories. Review of the medical record revealed Resident #27's weight on 03/26/24 taken by a sit-down scale was 115.8 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. A review of the MAR dated March 2024 revealed Resident #27 received Isosource 1.5 at 50 ml/hour continuous via the feeding tube from 03/01/24 until 03/19/24 when RD/LDN #310's recommendations to provide 240 ml bolus of Isosource 1.5 (1080 calories) and Isosource 1.5 at 80 ml/hour continuous from 6:00 P.M. until 6:00 A.M. (1440 calories) for a total caloric intake of 2520 calories were implemented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 5 of 12 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 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 0692 Level of Harm - Actual harm Residents Affected - Few Review of the medical record revealed Resident #27's weight on 04/05/24 taken by a sit-down scale was 116.2 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. Review of the medical record revealed no documented evidence Resident #27 was weighed for six weeks, between 04/06/24 and 05/20/24. Review of the medical record revealed Resident #27's weight on 05/21/24 taken by a stand-up scale was 111.5 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. Review of the medical record revealed Resident #27's weight on 06/05/24 taken by a stand-up scale was 110.8 pounds. This reflected a 34.2 pound weight loss since admission (a 23.6% weight loss). There was no documented evidence that the dietitian and physician were notified of the resident's weight. A review of physician progress notes for Resident #27 dated 02/20/24, 03/05/24, 03/12/24, 03/19/24, 03/27/24, 04/04/24, 04/16/24, 04/30/24, 05/05/24 and 05/07/24 revealed no documented evidence the physician was notified, aware of or addressed the resident's weight loss at the time of these visits. There was no documentation within the notes addressing Resident #27 weight loss. On 06/25/24 at 11:00 A.M. an interview with RD/LDN #310 verified Resident #27's weight loss of 34.2 pounds since admission to the facility. RD/LDN #310 also verified Resident #27 did not receive the recommended Isosource 1.5 at 70 ml/hour continuous via feeding tube as recommended from 02/05/24 through 03/19/24. On 06/25/24 at 1:00 P.M. an interview with the Director of Nursing (DON) verified Resident #27 did not receive the recommended Isosource 1.5 at 70 ml/hour continuous via feeding tube as recommended from 02/05/24 through 03/19/24. On 07/01/24 at 2:15 P.M. an observation of the scale Resident #27 had been weighed on revealed a Brecknel ramp scale that could be used as a stand-up scale or a wheelchair scale. A sticker on the back of the scale revealed a calibration service date of 08/01/23 with a return service date of 08/01/24. Regional Director of Clinical Services (RDCS) #313 verified the date on the scale at the time of the observation. This was the same scale used during the weights obtained above. On 07/01/24 at 2:20 P.M. an observation of the DON weighing Resident #27 revealed the resident's wheelchair weight was 37 pounds. The DON then placed Resident #27 in the wheelchair and wheeled him up the ramp on the scale. The weight of Resident #27 in the wheelchair was 147 pounds. The net weight for Resident #27 was 110 pounds representing a 35-pound weight loss since admission. The DON and RDCS #313 verified the weights at the time of the observation. On 07/01/24 at 3:00 P.M. an interview with the RDCS #313 verified there was no documented evidence within the physician progress notes for Resident #27 to indicate physician notification of weight loss. RDCS #313 also verified the physician did not address Resident #27's weight loss. Interview on 07/02/24 at 1:15 P.M. with Medical Doctor #315 revealed he was unaware of Resident #27's weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 6 of 12 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 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 0692 Interview on 07/02/24 at 2:05 P.M. with Nurse Practitioner #316 revealed neither she nor Medical Doctor #315 were notified of Resident #27's weight loss. Level of Harm - Actual harm Residents Affected - Few A review of the policy titled, Weight Assessment and Intervention, dated September 2008, revealed the following: • 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 7 of 12 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 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 0809 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and meal service times review, the facility failed to serve lunch in a timely manner. This affected 71 residents receiving meals from the facility. The facility identified three residents (#27, #40, and #44) as receiving nothing by mouth. The facility census was 74. Findings include: On 06/26/24 at 11:40 A.M. an observation of the lunch tray service began. A review of the menu revealed soft tacos and Spanish rice were to be served. The rice was on the stovetop cooking. An interview at the time of the observation with the Corporate Culinary Director (CCD) #314 verified the rice was not ready to serve, and the tray line should have begun at 11:30 A.M. On 06/26/14 at 12:15 P.M. an observation noted that no pureed food was prepared. The tray service for lunch had not started. CCD #314 verified the lack of pureed meals prepared, and the tray line had not started at the time of the observation. On06/26/24 at 12:39 P.M. an observation revealed tray service beginning. On 06/26/24 at 12:44 P.M. an observation revealed lunch trays going to the first-floor dining room. CCD #314 verified the lunch trays going to the dining room at the time of the observation. An interview with CCD #314 revealed the trays should have gone to the first-floor dining room at 12:00 P.M. On 06/26/24 at 12:48 P.M. an observation revealed lunch trays going to the first-floor blue hall. CCD #314 verified the lunch trays going to the first-floor blue hall at the time of the observation. An interview with CCD #314 revealed the trays should have gone to the first-floor blue hall at 12:15 P.M. On 06/26/24 at 1:00 P.M. an observation revealed lunch trays going to the second-floor blue hall. CCD #314 verified the lunch trays going to the second-floor blue hall at the time of the observation. An interview with CCD #314 revealed the trays should have gone to the second-floor blue hall at 12:30 P.M. On 06/26/24 at 1:16 P.M. an observation revealed lunch trays going to the second-floor green hall. CCD #314 verified the lunch trays going to the second-floor green hall at the time of the observation. An interview with CCD #314 revealed the trays should have gone to the second-floor green hall at 12:45 P.M. On 06/26/24 at 1:35 P.M. an observation revealed lunch trays going to the second-floor yellow hall. CCD #314 verified the lunch trays going to the second-floor yellow hall at the time of the observation. An interview with CCD #314 revealed the trays should have gone to the second-floor yellow hall at 1:00 P.M. On 06/26/24 at 1:47 P.M. an observation revealed lunch trays going to the second-floor red hall. CCD #314 verified the lunch trays going to the second-floor red hall at the time of the observation. An interview with CCD #314 revealed the trays should have gone to the second-floor red hall at 1:15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 8 of 12 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 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 0809 P.M. Level of Harm - Potential for minimal harm On 06/26/24 at 1:51 P.M. an interview with CCD #314 verified the lunch tray service line started over an hour late resulting in the lunches for the day being served late. Residents Affected - Many 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 9 of 12 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 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH (Nursing Home), staff interview, and facility policy review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) protocols. This affected two residents (#44 and #48) of 14 residents reviewed and identified as being on EBP. The facility census was 74. Residents Affected - Few Findings include: 1. A review of medical records for Resident #44 revealed an admission date of 12/16/23. Significant orders included management of a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach for feeding) and EBP. On 06/24/24 at 3:00 P.M. an observation of medication administration with Licensed Practical Nurse (LPN) #266 revealed LPN #266 administering carbamazepine 400 milligrams (mg) (anticonvulsant) via Resident #44's PEG tube. LPN #266 did not don a gown. LPN #266 verified the EBP sign on Resident #44's door. An interview at the time of the observation with LPN #266 revealed she did not know what EBP was. LPN #266 also verified she did not don a gown for the medication administration via the PEG tube. 2. A review of resident records for Resident #48 revealed an admission date of 05/26/24. Significant orders included EBP due to a left foot wound. On 06/24/24 at 3:50 P.M. an observation of incontinence care for Resident #48 revealed State Tested Nurse Aide (STNA) #235 did not don a gown to render the incontinence care. LPN #266 verified there was sign posted on Resident #48's door for EBP at the time of the observation. LPN #266 verified STNA # 235 did not have a gown on while rendering care. 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 F880 Infection Prevention and Control. Guidance under 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 10 of 12 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 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. 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 approved disinfectant. Point #29 under the same subsection stated to clean the bath. A review of the undated policy titled Housekeeping Guidelines revealed in point #8 the procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 11 of 12 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many for 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) Previous Versions Obsolete Event ID: Facility ID: 365355 If continuation sheet Page 12 of 12