Health inspection·January 9, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to timely provide care and services to a resident's change in condition. This affected one (Resident #40) of three residents reviewed for change in condition. The facility census was 136. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 12/14/24. Diagnoses included pain in right hip, low back pain, and disorders of bone density. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/20/24, revealed Resident #40 had intact cognition. Review of the care plan dated 12/16/24 revealed Resident #40 was at risk or had pain related to right hip and left shoulder pain. Interventions included observe for signs and symptoms of pain, assess pain, provide comfort measures, medicate per physician's order and consult with physician for ineffective pain relief. The nursing notes dated 12/30/24 at 5:00 P.M. revealed the nurse was notified by the Certified Nursing Assistant (CNA) that Resident #40 was on the floor in the resident's room. Upon entering her room, resident observed sitting on her buttocks with her lower extremities stretched outward in front of her. When asked what happened, a staff member stated the resident rolled out of bed while caring for her. This nurse assessed resident and vital signs were taken and within normal limits, resident denied head injury nor pain. No evident sign of injuries, full range of motion (ROM) of extremities. Review of the Social Worker #500's statement dated 01/02/25 revealed Resident #40 was going down to therapy and requested a follow up from her fall. The social worker brought the Assistant Director of Nursing (ADON) #307 into the conversation. Resident #40 explained she had pain her shoulder prior to the fall, but this pain was different. She was told by staff earlier in the day that she had bruising on her back. ADON #307 explained an x-ray would be ordered. Resident #40 appeared to be reluctant on getting the x-ray. Resident #40 was pleased with conversation and continued to go to scheduled therapy. Review of ADON #307's statement dated 01/02/25 revealed Social Worker #500 obtained ADON #307 to speak with Resident #40. Resident #40 explained stated she was having pain in her left shoulder that was not new but a little different. ADON #307 explained an x-ray would be ordered. There was nothing documented in the medical record on 01/02/25 and 01/03/25 regarding the physician being notified of Resident #40's reported pain in the left shoulder that was described by the (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 2 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 01/09/2025 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)