Health inspection·July 24, 2025

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. Page 1 of 2 365355 365355 07/24/2025 Gardens of Mayfield Village 6757 Mayfield Rd Mayfield Heights, OH 44124

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 365355 Page 2 of 2