Gardens of Mayfield Village

In the surveyor’s words

From the most serious findings on record at Gardens of Mayfield Village, in the surveyor’s own words.

• Actual harm, isolatedF686May 29, 2025

  3. Review of Resident #8's medical records revealed an admission date of 02/13/25 with diagnoses including bilateral lower extremity ulcers and pressure ulcer of the left heel. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition. Resident #8 required maximum (staff) assistance with bathing and personal hygiene. Review of care plan dated 04/23/25 revealed Resident #8 had a pressure ulcer to the left heel. Interventions included administer treatments as ordered. Review of physician orders for May 2025 revealed Resident #8 was ordered to cleanse left heel with normal saline, apply collagen (wound dressing used to promote healing), cover with an absorbent pad and wrap with gauze daily and as needed. Interview on 05/12/25 at 12:40 P.M. […]

• Actual harm, isolatedF689May 29, 2025

  4. Review of Resident #60's medical records revealed an admission date of 01/21/25. Diagnoses included dementia, muscle weakness and need for personal care assistance. Review of care plan dated 04/23/25 revealed Resident #60 resided on the secured unit related to decreased safety awareness. Resident #60 was a smoker. Interventions included instruct resident on the facility policy on smoking and notify charge nurse if it is suspected resident had violated smoking policy and Resident #60 required supervision while smoking. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had intact cognition. Review of smoking assessment dated [DATE] revealed Resident #60 was safe to smoke with supervision. Review of progress note dated 04/30/25 timed 12:24 P.M. […]

• Actual harm, isolatedF692Jul 2, 2024

  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. 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. […]

• Actual harm, isolatedF684Jun 5, 2024

  Based on observation, record review, interview and facility policy review, the facility failed to provide comprehensive, individualized and necessary diabetic ulcer (wound that commonly appears on the feet as a complication of diabetes often from lack of sensation or blood flow) assessment and care for Resident #151. This affected one resident (#151) out of three residents reviewed for diabetic/vascular/ pressure related wound care. The facility identified six residents (#111, #150, #151, #154, #162, and #163) with pressure/ vascular/ diabetic wounds. […]

• Actual harm, isolatedF686Apr 4, 2024

  Based on observation, record review, facility policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of an in-house acquired pressure ulcer for Resident #49. This affected one resident (#49) of three residents reviewed who were at risk for pressure ulcers. The facility census was 58. Actual Harm occurred on 03/26/24 when Resident #49, who was cognitively impaired and dependent on staff for mobility was found to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible and bone, tendon or muscles is not exposed. […]