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Deficiency Records for Gardens of Mayfield Village
A list of the most recent deficiencies for Gardens of Mayfield Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Gardens of Mayfield Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-08-08 | 2024-08-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-08 | 2024-08-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-08 | 2024-08-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-08 | 2024-08-28 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-08-08 | 2024-08-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-08 | 2024-08-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-08 | 2024-08-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-08 | 2024-08-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-02 | 2024-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-02 | 2024-08-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-05 | 2024-08-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-05 | 2024-08-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-09 | 2024-08-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-04 | 2024-08-28 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-04 | 2024-08-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-04 | 2024-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-04 | 2024-08-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-02 | 2024-08-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-02 | 2024-08-08 | Y |
| 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. | Health | 2024-07-02 | 2024-08-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-02 | 2024-08-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-09 | 2024-08-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-09 | 2024-08-08 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-04-04 | 2024-08-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-04 | 2024-08-08 | Y |
| 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. | Health | 2024-04-04 | 2024-08-08 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-04-04 | 2024-08-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-07 | 2024-03-20 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-03-07 | 2024-03-20 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-03-07 | 2024-03-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-07 | 2024-03-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-03-20 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-07 | 2024-03-20 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-11-06 | 2023-11-20 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-11-06 | 2023-11-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-06 | 2023-11-20 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-03-29 | 2023-05-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-30 | 2023-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-30 | 2023-04-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-30 | 2023-04-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-30 | 2023-04-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-30 | 2023-04-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-30 | 2023-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-04-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-30 | 2023-04-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-30 | 2023-04-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-30 | 2023-04-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-30 | 2023-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-30 | 2023-04-28 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-30 | 2023-04-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-30 | 2023-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-30 | 2023-04-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-30 | 2023-04-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-30 | 2023-04-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-30 | 2023-04-28 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-03-30 | 2023-04-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-20 | 2022-11-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-20 | 2022-11-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-20 | 2022-11-28 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-20 | 2022-11-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-20 | 2022-11-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-20 | 2022-11-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-20 | 2022-11-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-20 | 2022-06-15 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-01-24 | 2022-03-02 | Y |
| 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. | Health | 2019-11-06 | 2020-01-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-06 | 2020-01-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-06 | 2020-01-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-06 | 2020-01-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-06 | 2020-01-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-06 | 2020-01-13 | N |
| 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. | Health | 2019-11-06 | 2020-01-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-06 | 2020-01-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-07 | 2020-01-13 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-11-07 | 2019-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-27 | 2018-11-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-09-27 | 2018-11-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-27 | 2018-11-02 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-09-27 | 2018-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-27 | 2018-11-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-27 | 2018-11-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-09-27 | 2018-11-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-27 | 2018-11-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-09-27 | 2018-11-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-09-27 | 2018-11-02 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-09-27 | 2018-11-02 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2018-09-27 | 2018-11-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Meet other general requirements. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-28 | 2018-11-02 | N |
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