Cycle 1
Health 2025-05-29 · Fire 2025-05-29
43 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Mayfield Heights, OH
Gardens Of Mayfield Village
2-star overall rating with 1-star inspections with Special Focus status with $153,497 in total fines with 43 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
6757 Mayfield Rd, Mayfield Heights, OH
(440) 473-0090
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,551
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 65.00% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.35
Baseline 2.59 hours · Performance 3.50 hours · Measure score 2.35 · Achievement 1.47 · Improvement 2.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 109 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 47.9% |
92.4%
44.5 pts worse
|
93.4%
45.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 44.1% · Q3 48.3% · Q4 64.9% · 4Q avg 47.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 35.9% |
94.5%
58.6 pts worse
|
95.5%
59.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 35.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 39.0% |
26.1%
12.9 pts worse
|
11.4%
27.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.5% · Q2 41.7% · Q3 22.6% · Q4 18.8% · 4Q avg 39.0% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.3% · Q3 1.7% · Q4 10.9% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
25.4%
5.7 pts better
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 16.4% · Q3 18.6% · Q4 23.6% · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
11.5%
6.3 pts worse
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 15.2% · Q3 14.7% · Q4 17.1% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.0% |
7.7%
7.7 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.9% |
6.2%
5.3 pts better
|
14.9%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
21.7%
8.5 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 31.7% · Q3 38.4% · Q4 20.8% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
3.7%
1.4 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.7% · Q3 6.2% · Q4 5.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 13.2% |
78.1%
64.9 pts worse
|
81.7%
68.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 10.5% · Q3 9.7% · Q4 25.0% · 4Q avg 13.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.2%
3 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 18.4% |
75.6%
57.2 pts worse
|
79.7%
61.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 18.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
52 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-11-06 · Fire 2019-11-06
11 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-29
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-25
E · Potential for more than minimal harm
2025-05-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-05-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-05-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-22
F · Potential for more than minimal harm
2023-03-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-28
F · Potential for more than minimal harm
2019-11-06
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2020-01-13
F · Potential for more than minimal harm
2019-11-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-13
F · Potential for more than minimal harm
2019-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-13
F · Potential for more than minimal harm
2019-11-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-13
F · Potential for more than minimal harm
2019-11-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2020-01-13
E · Potential for more than minimal harm
2019-11-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-01-13
E · Potential for more than minimal harm
2019-11-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-13
E · Potential for more than minimal harm
2019-11-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-01-13
E · Potential for more than minimal harm
2019-11-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-13
C · Minimal harm
2019-11-06
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-12-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-27
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-08-27
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-08-28
D · Potential for more than minimal harm
2025-08-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-28
E · Potential for more than minimal harm
2025-07-24
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-25
G · Actual harm
2025-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-24
G · Actual harm
2025-05-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-05-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-05-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-07-25
E · Potential for more than minimal harm
2025-05-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-05-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-05-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-05-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-05-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-07-24
B · Minimal harm
2025-05-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-24
E · Potential for more than minimal harm
2024-08-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-08-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-08-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-08-08
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-08-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-08-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-28
C · Minimal harm
2024-08-08
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-08-28
G · Actual harm
2024-07-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-28
C · Minimal harm
2024-07-02
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-08-08
G · Actual harm
2024-06-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-06-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-05-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-05-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-08
G · Actual harm
2024-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-04-04
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-04-04
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-04-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-04-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-04-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-04-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-03-07
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-03-07
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-03-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-11-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-06
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-06
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-03-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-30
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-30
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-04-28
C · Minimal harm
2023-03-30
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-04-28
E · Potential for more than minimal harm
2019-11-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2020-01-13
E · Potential for more than minimal harm
2019-11-06
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2020-01-13
E · Potential for more than minimal harm
2019-11-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-11-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-11-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-11-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-11-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-11-06
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-01-13
Penalties and ownership
What sits behind the stars
$113,035
2025-05-29
Fine
Fine · fine $113,035
Fine
$0
2025-05-29
Payment Denial
Payment Denial · denial start 2025-06-26 · 29 days
29 day denial
$40,462
2024-04-04
Fine
Fine · fine $40,462
Fine
$0
2024-04-04
Payment Denial
Payment Denial · denial start 2024-05-01 · 119 days
119 day denial
Ownership
Hoch, Michael
5% Or Greater Indirect Ownership Interest · Individual
Mayfield Opco Member LLC
5% Or Greater Direct Ownership Interest · Organization
Deutsch, Paul
W-2 Managing Employee · Individual
Katz, Larry
Corporate Director · Individual
Katz, Larry
Corporate Officer · Individual
Lahasky, Ephram
Corporate Director · Individual
Lahasky, Ephram
Corporate Officer · Individual
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