Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record
review of Resident #30 revealed she was hospitalized [DATE] following a fall and returned to the facility
06/29/23. No evidence could be found indicating the resident or family received written notification of the
reason for transfer to the hospital.
Interview with Resident #30's power of attorney on 08/08/23 at 2:13 P.M. revealed the facility informed her
verbally of the hospitalization and gave her a paper bed hold notice, however, they did not provide a written
notification for the reason for the transfer to the hospital.
4. Record review of Resident #136 revealed she was hospitalized on [DATE] and did not return to the
facility. No evidence could be found indicating the resident or family received written notification of the
reason for the transfer to the hospital.
Based on resident representative, staff interviews and record review, the facility failed to provide the
resident and resident representative a written notification for the reason for transfer to the hospital for
Resident #28, #30, #67, #135 and #136. This affected five residents (#28, #30, #67, #135, and #136) of five
residents reviewed for hospitalizations. The facility census was 135.
Findings include:
1.Review of the medical record for Resident #28 revealed an admission date of 09/18/19. Diagnoses
included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, dysphagia, and
congestive heart failure (CHF). Resident #28 was sent to the hospital on [DATE] due to a change in
condition, as documented in a nurse's note dated 05/13/23 at 1:24 P.M., following a physician order to send
the resident to the emergency room. The medical record showed no evidence Resident #28 nor their power
of attorney (POA) was provided a written notification for the reason for transfer to the hospital.
2.Review of the closed medical record for Resident #135 revealed an admission date of 07/01/23.
Diagnoses included stroke, left eye blindness, low vision right eye, hyperlipidemia, hypertension, and
seizures. Resident #135 was transferred to the emergency department via ambulance on 07/03/23 per a
nurses note dated 07/03/23 at 4:43 P.M. The medical record showed no evidence Resident #135 nor their
representative was provided a written notification for the reason for transfer to the hospital.
#5. Review of the medial record for Resident #67 revealed an admission date of 03/27/23 with diagnoses of
chronic diastolic congestive heart failure, cardiomyopathy, unspecified atrial fibrillation, hypertensive heart
disease with heart failure, and hypertension and a discharge to the hospital on
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
366350
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366350
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of McGregor and Amasa Stone
14900 Private Dr
East Cleveland, OH 44112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
[DATE] and returned to the facility on [DATE]. The record contained no evidence that a written notification of
the reason for the transfer had been given to the resident or the resident's representative.
Interview was conducted on 08/09/23 at 11:32 A.M. with the Administrator who verified the facility did not
provide written notice of transfer to the hospital to Resident #28, #30, #67, #135, #136 or their
representatives because the facility practice was to notify all residents and resident representatives verbally
if a resident needed transferred to the hospital. The Administrator explained the facility did provide bed hold
notices, but only did verbal notifications to residents and resident representatives on reason for the transfer
to the hospital.
Review of the undated facility policy titled Transfer and Discharge Guidelines, under the area notice, before
a facility transfers or discharges a resident permanently, the facility must: notify the resident and, if known, a
family member or legal representative of the resident transfer or discharge and the reasons for the move in
writing and in a language and manner they understand.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366350
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366350
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of McGregor and Amasa Stone
14900 Private Dr
East Cleveland, OH 44112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on observation, record review, hospital record review and interview the facility failed to provide
adequate supervision and intervention to prevent and mitigate a fall with injury for Resident #30.
Actual harm occurred on 06/08/23 when Resident #30, who required the assistance of two staff for bed
mobility, fell from a bed in high position when receiving incontinence care by one staff member resulting in a
right hip dislocation and hospitalization. This affected one resident (#30) of two residents reviewed for
accident hazards. The total census was 135.
Findings include:
Record review for Resident #30 revealed the resident was admitted to the facility 10/11/21 and had
diagnoses including cognitive communication deficit, osteoarthritis, and anxiety disorder.
Review of the care plan for falls, dated 10/11/21, identified the need to provide a safe environment,
including keeping the bed in low position. The plan of care interventions were updated on 06/08/23 for the
use of fall mats to be kept on both sides of the resident's bed.
Review of a fall assessment, dated 04/07/23 revealed Resident #30 was at high risk for falls.
Review the most current occupational therapy assessment, dated 05/09/23, revealed Resident #30 had
total dependence on staff for sitting balance, toileting, hygiene, and all other self-care activities of daily
living.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/03/23 revealed she had moderate
cognitive impairment and required total dependence on two or more staff to provide bed mobility, including
turns.
Review of Resident #30's progress notes revealed a note dated 06/08/23 at 10:38 P.M. indicating State
Tested Nursing Assistant (STNA) notified the nurse the resident rolled onto the floor during patient care.
The nurse entered and found the resident lying on her side by the bed. The resident said, I rolled out of
bed, and denied pain. Assessment at the time showed no sign of injury, however, notes on 06/09/23
revealed the resident complained of pain. An x-ray done the same day revealed the resident had a
dislocated hip and was sent to the emergency room.
Review of Resident #30's hospital documentation revealed the resident was admitted to the hospital and
received a right total hip arthroplasty closed reduction under anesthesia (a procedure to put the hip back in
place without need of incision). She was hospitalized until 06/29/23 when she returned to the facility.
Review of a facility fall investigation for Resident #30's revealed the resident rolled out of bed on 06/08/23.
A skin assessment was (initially) completed with no injuries noted. Bilateral safety mats to the side of the
bed were applied in response to the fall. The next day the resident had complaints of pain in the right hip,
and an x-ray revealed she had an injury. A witness statement from STNA #816 dated 06/09/23 revealed she
rolled Resident #30 onto her right side, then went to the sink to retrieve an extra towel and the resident fell
over as soon as she turned back around. STNA #816
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366350
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366350
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of McGregor and Amasa Stone
14900 Private Dr
East Cleveland, OH 44112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
received discipline by the facility and education to ensure residents were in a safe position prior to walking
away.
Level of Harm - Actual harm
Residents Affected - Few
Observation of Resident #30 on 08/07/23 at 11:43 A.M. revealed she was not interview able and
demonstrated no verbal or nonverbal signs of pain. She did not make any motions with her hands or arms
nor demonstrate any ability to move around by herself in the bed.
Interview with Resident #30's power of attorney on 08/08/23 at 2:13 P.M. revealed that on 06/08/23 at
roughly 11:00 P.M. the facility informed her Resident #30 had a fall. The nurse informed her the fall occurred
when the aide turned their back on the resident during incontinence care. The nurse said she believed the
air mattress might be responsible, which may have shifted beneath the resident and caused her to roll. The
next day the facility took x-rays, found had dislocated her hip, and they sent her to the hospital. Resident
#30 was admitted to the hospital for 22 days, although she was treated for other conditions besides the
dislocated hip during the hospitalization. Resident #30 was not capable of independent positioning in the
bed.
Interview with Licensed Practical Nurse (LPN) #982 on 08/09/23 at 3:43 P.M. revealed she was Resident
#30's nurse at the time of her fall on 06/08/23. The LPN revealed Resident #30 was dependent on staff for
bed mobility both before and after the fall and there should have been two staff members present when
giving incontinence care. At roughly 10:30 P.M. on 06/08/23, STNA #816 informed her Resident #30 fell.
The nurse arrived at the bedside to find the resident laying on her right side next to the right side of the bed.
The bed was in a high position due to the fall occurring during incontinence care. The resident denied pain
at the time, denied hitting her head, and a skin assessment revealed no evidence of injury.
Interview with STNA #816 08/09/23 at 5:18 P.M. revealed on the evening of 06/08/23, Resident #30 had a
large bowel movement and STNA #816 provided incontinence care without other staff in the room. She said
the resident usually only needed one staff member to provide incontinence care, although sometimes
needed two staff if they were unfamiliar with the resident. She stated she ran out of towels while giving care
and left the resident on her right side to go to the bathroom to get more. STNA #816 stated she heard the
resident fall to the floor while she was in the bathroom and came out to find the resident laying on the floor
on her right side. STNA #816 immediately retrieved the nurse. The STNA stated Resident #30 denied pain
all throughout that night. The resident could grip the bed 'a little bit' during turns, but otherwise had no
ability to contribute to bed mobility both before and after the fall.
The surveyor confirmed the above record review findings with the Director of Nursing during an interview
on 08/10/23 at 9:55 A.M.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366350
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366350
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of McGregor and Amasa Stone
14900 Private Dr
East Cleveland, OH 44112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record
review of Resident #71 revealed she was admitted to the facility 07/23/20 and had diagnoses including
unspecified dementia, anxiety disorder, auditory hallucinations, and major depressive disorder.
Review of the facility records showing the list of residents reviewed monthly by the pharmacist for January
2023, February 2023, March 2023 and April 2023 revealed no documentation of pharmacy reviews
completed for Resident #71.
3. Record review of Resident #9 revealed she was admitted to the facility 02/22/20 and had diagnoses
including multiple sclerosis, major depressive disorder, and chronic kidney disease.
Review of the facility records showing the list of residents reviewed monthly by the pharmacist for January
2023, February 2023, March 2023 and April 2023 revealed no documentation of pharmacy reviews
completed for Resident #9. 4. Review of the medical record for Resident #3 revealed an admission date of
01/04/21. Diagnoses included diabetes mellitus type 2, hyperglycemia, chronic obstructive pulmonary
disease, ad major depressive disorder.
Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had
moderately impaired cognition, had no behaviors, required extensive assistance of two staff for bed mobility
and transfers. The resident also received insulin, antianxiety medication, diuretic, and opioids.
Review of the facility records showing the list of residents reviewed monthly by the pharmacist for October
2022, January 2023, February 2023, March 2023, June 2023 and July 2023 revealed no documentation of
pharmacy reviews completed for Resident #3.
Interview was conducted on 08/10/23 at approximately 11:00 A.M. with the Director of Nursing (DON) who
explained her former Assistant Director of Nursing (ADON) had kept track of the monthly pharmacy review
binder containing the lists of residents reviewed by the pharmacist each month, the ADON no longer
worked for the facility and the DON could find no record at all of pharmacy reviewes from October 2022.
The DON verified for Resident #3, #9, #35 and #71 there was no evidence those residents had received
monthly pharmacy reviews for the months in question by the surveyors.
Based on interview and record review, the facility failed to ensure monthly pharmacy reviews were
completed for Resident #3, #9, #35 and #71. This affected four residents, (Resident #3, #9, #35, and #71),
out of five residents reviewed for unnecessary medications. Facility census was 135.
Findings include:
#1. Resident #35's medical record revealed an admission date of 12/3/19 with diagnosis to include Multiple
Sclerosis (MS), muscle wasting/atrophy right upper arm, hypertension, epilepsy, spondylolysis lumbosacral
region, anxiety disorder and sleep apnea.
Record review of the care plan dated 06/07/23 revealed antipsychotic medications used for the diagnosis of
insomnia, depression, and schizoaffective disorder. Interventions included to administer psychotropic
medications as ordered by physician, monitor for side effects, attempt general dose
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366350
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366350
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of McGregor and Amasa Stone
14900 Private Dr
East Cleveland, OH 44112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
reduction (GDR) as indicated, and referral to psychiatric services.
Level of Harm - Minimal harm
or potential for actual harm
Record review of the physician orders for Resident #35 for August 2023 revealed orders for Escitalopram
Oxalate 20 milligram (MG) for depression, Remeron 30 MG for depression, and Latuda 40 MG for
depression.
Residents Affected - Some
Record review of the Medication Administration Record (MAR) for August 2023 revealed Resident #35
received Escitalopram Oxalate 20 milligram (MG), Remeron 30 MG for depression, and Latuda 40 MG
everyday as ordered.
Review of the facility records showing the list of residents reviewed monthly by the pharmacist for October
2022, January 2023, February 2023, and March 2023 revealed no documentation of pharmacy reviews
completed for Resident #35.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366350
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366350
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/10/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of McGregor and Amasa Stone
14900 Private Dr
East Cleveland, OH 44112
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and interview, the facility failed to ensure all nursing unit serveries were maintained
in a clean and sanitary manner to prevent the risk of attracting pests, and contamination of clean cups for
use by the residents. This affected 22 residents (#14, #19, #29, #30, #31, #37, #40, #58, #61, #66, #79,
#80, #83, #86, #95, #101, #108, #110, #115, #120, #122, and #387) who resided on one South nursing
unit, 22 residents (#2, #10, #11, #36, #46, #56, #70, #94, #97, #123, #127, #287, #288, #289, #290, #291,
#292, #293, #294, #295, #296, and #297) who resided on two North nursing unit, and 25 residents (#1, #5,
#9, #17, #18, #20, #24, #41, #43, #49, #51, #52, #59, #60, #62, #69, #71, #74, #77, #78, #89, #99, #112,
#117, and #118) who resided on three South nursing unit. The facility census was 135.
Findings include:
Observations on 08/09/23 between 10:11 A.M. through 10:27 A.M. of the tour of the nursing unit serveries
with Certified Dietary Manager (CDM) #931 revealed the three South, two North and one South nursing
unit serveries were not maintained in a clean and sanitary manner. The three South servery had food
and/or beverage spills and sugar packets on the floor, salt or sugar spilled on a tray holding clean cups,
dried reddish food splatter near the steam table, and brownish drippings on white cabinet doors where the
microwave was located. The reach-in freezer had spillage and food splatter on the inside bottom part of the
freezer. Observations in the two North nursing unit servery revealed dried brownish spillage on the white
cabinets near the microwave and on the cabinets near sink. The counter near the sink had various build up
of food debris. Observed on the one South nursing unit servery inside of the reach-in freezer there was a
reddish spillage and various food residue stains and ice frozen to the bottom of the inside freezer.
Interview on 08/09/23 between 10:11 A.M. through 10:27 A.M., CDM #931 verified the above findings and
stated she would have it all cleaned up. CDM #931 stated housekeeping was responsible for the floors and
the dietary staff was responsible for wiping everything down after each meal.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366350
If continuation sheet
Page 7 of 7
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
FAQ · About this visit
Common questions about this visit
What happened during the August 10, 2023 survey of GARDENS OF MCGREGOR AND AMASA STONE?
This was a inspection survey of GARDENS OF MCGREGOR AND AMASA STONE on August 10, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDENS OF MCGREGOR AND AMASA STONE on August 10, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.