Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Altercare Of Mayfield Village, Inc during CMS and state inspections, most recent first.
An LPN found a Full Code resident unresponsive and started CPR, but CPR was stopped before EMS arrived and without a physician order. 911 was miscommunicated or canceled, EMS never entered the room, and the resident was later pronounced dead in the facility. The resident had multiple chronic conditions, recent decline, and no documented change from Full Code status.
A newly admitted resident experienced a delay in receiving necessary medications due to missing hard copy prescriptions for Tizanidine and Oxycodone. The admitting nurse assumed the facility physician would handle the prescriptions, but they were not sent until the following day, causing the resident to experience unmanaged pain.
A facility failed to develop a comprehensive care plan for a resident with a PICC line and IV antibiotics, omitting necessary interventions for her condition. The resident's care plan lacked details on maintaining the PICC line and monitoring antibiotics, leading to missed dressing changes and improper documentation. Staff interviews revealed issues with documentation and unfamiliarity with the system, contributing to the oversight.
A resident with endocarditis did not receive proper PICC line maintenance and IV antibiotic administration due to missing orders and documentation. The care plan lacked interventions for the PICC line, and the dressing was not changed as required. The oversight was discovered when the resident's daughter noticed the outdated dressing during a hospital visit.
A resident with multiple diagnoses, including osteomyelitis and diabetes, did not have their PICC line dressing changed as ordered for nearly three weeks. Despite physician orders and facility policy requiring changes every seven days, the dressing was not changed between 03/26/24 and 04/16/24, leading to a confirmed deficiency.
Premature discontinuation of CPR and failure to obtain EMS response for a Full Code resident
Penalty
Summary
Resident #46 had a Full Code status and multiple significant diagnoses, including dysphagia, communication deficit, weakness, aphasia, heart failure, hypertension, atherosclerotic heart disease, type 2 diabetes, convulsions, Parkinsonism, and hyperlipidemia. The resident had been admitted from a short-term hospital and was documented as having impaired short-term memory but intact long-term memory, being alert and oriented to self, place, and time, and having unclear speech but being able to understand others. The medical record showed no physician orders changing the resident’s advance directives from Full Code. On the morning of the event, the resident had recently refused medications and had been noted to have elevated WBCs and a change in condition. When the day shift LPN entered the room to obtain vital signs, the resident was found unresponsive and without signs of life. The LPN initiated CPR, but CPR was then discontinued before EMS arrived and without a physician order. The record and interviews showed that the resident was described as blue, cold, and stiff, and staff disagreed about whether EMS had actually arrived; however, the 911 records and body camera footage showed the facility call was hung up, the dispatcher called back, and police later responded after being told there was no emergency. EMS never entered the facility. The physician stated he had instructed staff to start ACLS until advance directives were verified and denied telling staff to stop CPR or call the time of death. The DON stated that if a resident was Full Code, staff were to initiate CPR and continue until EMS arrived, and only a physician could determine when CPR could stop. The report also states that an LPN was not qualified under Ohio requirements to pronounce death. The resident was later pronounced deceased in the facility, and the death certificate listed myocardial infarction and coronary artery atherosclerosis as the cause of death.
Delayed Medication Administration for New Resident
Penalty
Summary
The facility failed to ensure timely medication administration for a newly admitted resident, Resident #41, affecting her pain management and muscle spasm treatment. Upon admission, the resident's medical record indicated a need for medications including Tizanidine for muscle spasms and Oxycodone for pain management. However, these medications were not available in the initial shipment from the pharmacy and were not administered until the afternoon following her admission. The delay in medication administration was due to a lack of hard copy prescriptions for Tizanidine and Oxycodone, which were required by the pharmacy. The admitting nurse did not have these prescriptions and assumed the facility physician would handle the electronic prescription process. The morning nurse discovered the hard copy prescriptions in a sealed envelope from the hospital and expedited their delivery to the pharmacy, but this was not done until the following day. Interviews with the facility staff and the resident revealed that the resident experienced pain due to the unavailability of her Oxycodone medication. The facility's procedure for admitting new residents included steps for ensuring medication orders were sent to the pharmacy, but the process was not followed effectively in this case, leading to a delay in the resident receiving her necessary medications.
Failure to Develop Comprehensive Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for a resident with a peripherally inserted central catheter (PICC) line and intravenous (IV) antibiotics. The resident, who was admitted with diagnoses including endocarditis, did not have a care plan addressing the maintenance of her PICC line or the monitoring of her IV antibiotics. The care plan only included areas related to activities and nutrition, omitting critical interventions for her medical condition. Upon review, it was found that the resident had physician orders for antibiotics and PICC line maintenance, including flushing the line and changing the dressing and IV tubing. However, there was no documented evidence that these orders were followed before a certain date, and the resident's PICC line dressing was not changed as frequently as required. This oversight was discovered when the resident was taken to the hospital, where it was noted that her PICC line dressing had not been changed for 18 days, contrary to the seven-day requirement. Interviews with facility staff revealed that the oversight was due to a lack of proper documentation and unfamiliarity with the facility's electronic documentation system. An agency nurse admitted to mistakenly signing off on a dressing change that was not performed. The facility's policy required a comprehensive care plan to be developed within 21 days of admission, but it did not specify what should be included in the care plan, contributing to the deficiency.
Deficiency in PICC Line Maintenance and IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure proper maintenance and care of a resident's peripherally inserted central catheter (PICC) line, which was crucial for administering intravenous (IV) antibiotics for endocarditis. The resident's care plan did not include interventions related to the PICC line or the IV antibiotic use, despite the resident's serious condition. The medical record review revealed that the resident had orders for IV antibiotics and PICC line maintenance, including flushing the line before and after antibiotic therapy, checking the site every shift, changing the IV tubing every 24 hours, and changing the dressing every seven days. However, these orders were not obtained or documented until a week after the resident's admission. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that the resident received IV antibiotics as ordered, but there was no evidence of the PICC line being flushed or the site being assessed before 11/08/24. Additionally, the dressing change was not documented as completed until 11/08/24 and 11/15/24, despite the dressing being dated 10/29/24, indicating it was overdue for a change. The resident's daughter discovered the outdated dressing during a hospital visit, raising concerns about the risk of infection, especially given the resident's treatment for a heart infection. Interviews with facility staff, including the Director of Nursing (DON) and a regional nurse, confirmed the oversight in obtaining and documenting the necessary orders for PICC line maintenance. The agency RN admitted to mistakenly signing off on a dressing change due to unfamiliarity with the facility's electronic documentation system. The facility's policies on PICC line care, flushing, and tubing setup were not followed, leading to the deficiency in providing safe and appropriate IV fluid administration for the resident.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to change Resident #38's PICC line dressing as ordered. Resident #38, who had diagnoses including osteomyelitis of the vertebra, discitis, dorsalgia, diabetes mellitus type 2, and chronic kidney disease stage 3, was admitted on [DATE]. The resident had no cognitive impairment according to the Admission Minimum Data Set (MDS) assessment completed on 03/28/24. The physician's orders required the PICC line dressing to be changed every seven days and as needed (PRN). However, the dressing was not changed between 03/26/24 and 04/16/24, despite the resident's complaints and the facility's policy requiring changes every seven days or immediately if compromised. The Treatment Administration Record (TAR) and progress notes confirmed the lack of dressing changes during this period, and the Assistant Director of Nursing (ADON) verified the non-compliance with the orders. Observation and interview on 04/17/24 revealed that Resident #38 complained about the lack of timely PICC line dressing changes, stating it had been about two weeks since the last change before it was finally done on 04/16/24. The facility's policy on dressing change and care of PICC lines aimed to reduce the risk of systemic infections by ensuring dressings were changed every seven days or immediately if compromised. The failure to adhere to these orders and policies resulted in a deficiency, as confirmed by the ADON and documented evidence. This deficiency was investigated under Complaint Number OH00152974.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mayfield Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Pointe Health & Rehab Center | 1.8 mi | ★★★★★ | 10 | 1 |
| Grande Pointe Healthcare Commu | 2.1 mi | ★★★★★ | 3 | 0 |
| Wickliffe Country Place | 3 mi | ★★★★★ | 3 | 0 |
| Tranquility Of Richmond Heights | 3.2 mi | ★★★★★ | 0 | 0 |
| Gardens Of Mayfield Village | 3.2 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.