F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation, interview and review of facility policy, the facility did not ensure a comfortable
environment for Resident #24. This affected one resident (#24) of three residents interviewed for physical
environment and had potential to affect an additional 24 residents (#7, #11, #13, #14, #19, #21, #23, 25,
#28, #29, #31, #34, #35, #38, #40, #41, #44, #45, #47, #50, #53, #57, #58 and #59 residing on the second
floor. The facility census was 63. Findings include:An interview on 07/22/25 at 10:00 A.M. with Maintenance
Director (MD) #302 revealed he believed the highest ambient air temperature for the facility should be 71
degrees Fahrenheit (F) and as low as 65 degrees F. MD #302 also stated he was unaware of any resident
concerns regarding ambient air temperatures. An interview on 07/22/25 at 11:06 A.M. with Resident #24
revealed the facility felt cold to him especially during the night and early morning. An observation was
conducted with the Administrator on 07/22/25 at 11:23 A.M. on the 260's hall where the ambient air
temperature was read at 63F using a facility thermometer. In the common area of the second floor at the
nursing station, the ambient air temperature was 69F and the 200 hall common area had an ambient air
temperature of 67 F which was below the regulatory required facility temperature range of 71 degrees F to
81 degrees F. The Administrator verified the temperatures at the time of the observation. The Administrator
questioned the accuracy of the facility thermometer used to measure the temperatures. A second
thermometer, purchased new by the facility, measured a second set of ambient air temperatures which
were two degrees lower than the prior temperatures as stated above and this was verified by the
Administrator at the time of the observation. Record review of the facility's environmental temperature policy
dated 01/03/22 revealed the facility was to maintain an air temperature between 71 F to 81 F.This
deficiency represents non-compliance investigated under Complaint Number 1311263 and 1311264 and is
a recite to the annual survey completed 05/29/25.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
365355
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
07/24/2025
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, interview, and review of facility policy, the facility did not ensure Resident #63's
urinary catheter device was properly secured. This affected one resident (#63) of two residents reviewed for
urinary catheters. The census was 63.Findings include: Record review for Resident #63 revealed an
admission date of 04/09/25 with diagnoses including unspecified dementia, and neuromuscular dysfunction
of the bladder. Resident #63 had an active physician order and care plan dated 06/20/25 to maintain a
securement device for the urinary catheter to prevent movement and urethral traction. This was to be
monitored every shift, which was documented done as ordered on the first shift of 07/23/25. Further review
of the care plan revealed no documented behaviors for Resident #63 removing his securement
device.Review of the minimum data set (MDS) 3.0 assessment dated [DATE] identified Resident #63 to
have moderate cognitive impairment and needing substantial assistance for toileting. Review of progress
notes for Resident #63 for May 2025, June 2025 and July 2025 revealed no documented behaviors
regarding Resident #63 removing the securement device. Observation of a catheter care procedure for
Resident #63 on 07/23/25 at 3:02 P.M. by Certified Nurse Aide (CNA) #901 and the Director of Nursing
(DON) revealed the resident did not have a catheter securement device in place to prevent motion of the
lower tubing or bag from potentially tugging on the catheter insertion site.Interview with CNA #901 during
the above-noted observation revealed she had seen a securement device on Resident #63 in the past, but
she had provided personal care for him earlier in the day and did not see one on him.Interview with the
DON at 3:40 P.M. on 07/23/25 confirmed Resident #63 had an order and care plan for a catheter
securement device and none was in place during the catheter care. Interview with Licensed Practical Nurse
#902 on 07/23/25 at 3:44 P.M. revealed she was Resident #63's nurse on this date. She did not check the
resident for catheter securement placement today, however she recalled seeing it on him in the
past.Interview with Consultant Registered Nurse (RN) #903 on 07/24/25 at 8:42 A.M. revealed RN #903
stated the facility applied a securement device to Resident #63's leg following the observed catheter care,
however, he removed it. RN #903 stated the resident may have removed the device independently shortly
prior to the catheter care observation. The surveyor confirmed with her at this time that Resident #63 had
no notes or care plan indicating a behavior of removing catheter securement devices. Review of the
facility's catheter care policy dated 09/2014 revealed staff were to ensure the catheter remained secured
with a leg strap to reduce friction and movement at the insertion site.This deficiency is a recite to the annual
survey completed 05/29/25.
Event ID:
Facility ID:
365355
If continuation sheet
Page 2 of 2
