Health inspection·August 14, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of facility policy, the facility failed to ensure Resident #45 received appropriate care and services for a non-pressure related wound, including wound treatments as ordered and accurate documentation regarding the completion of the wound treatments. This finding affected one (Resident #45) of six residents reviewed for non-pressure skin conditions.Findings Include: Review of Resident #45's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the right lower limb, primary osteoarthritis of the knee and essential hypertension.Review of Resident #45's physician orders revealed an order dated 07/29/25 (discontinued 08/07/25) to cleanse the left lateral foot open area with normal saline (NS), pat dry, apply Santyl and calcium alginate to the wound bed and cover with a foam dressing every night shift for wound care; an order dated 08/07/25 (discontinued 08/13/25) to cleanse the left lateral foot open area with NS, pat dry, apply Santyl and calcium alginate to the wound bed and cover with a foam dressing and apply an ace wrap every night shift for wound care; and an order dated 08/13/25 to cleanse the left lateral foot open area with NS, pat dry, apply Santyl and calcium alginate to the wound bed and cover with a foam dressing and apply an ace wrap every evening shift for wound care.Review of Resident #45's skin care plan revealed an intervention dated 07/29/25 for the resident to receive treatments per the physician's order.Review of Resident #45's wound evaluation notes dated 08/07/25 revealed the resident had a diabetic ulcer to her left lateral malleolus measuring 1.2 centimeters (cm) by 2 cm by an undetermined depth with 100 percent (%) slough at the wound base. The note revealed the treatment plan for the wound included the importance of adhering to prescribed treatments and dressing changes to prevent infection. Review of Resident #45's Treatment Administration Record (TAR) from 08/01/25 to 08/14/25 revealed Licensed Practical Nurse (LPN) #542 provided wound care on 08/03/25, 08/07/25, 08/08/25 and 08/11/25.Interview on 08/11/25 at 10:37 A.M. with Resident #45 revealed she was not getting wound care as ordered. Resident #45 said she received wound care on 08/07/25 by Registered Nurse (RN) #626 and Wound Nurse Practitioner #740 and told them she was not receiving wound care daily. She was told by RN #626 that she would look into the issue. Resident #45 said she did not receive wound care again until 08/10/25 when she asked the day shift nurse to change her bandage because it was hurting.Interview on 8/12/25 at 4:20 P.M. with Resident #45 and RN #626 revealed RN #626 confirmed the conversation with Resident #45 from 08/07/25 about wound care not being completed daily. Resident #45 also revealed that it was one nurse that was not completing the wound care. RN #626 confirmed she had spoken with the nurse about falsifying records and they were given a verbal warning. Resident #45 stated she had not received wound care since 08/10/25.Interview on 08/12/25 at 4:40 P.M. with RN #626 revealed the nurse not providing the wound care was identified as LPN #542.Observation on 8/12/25 at 4:23 P.M. of RN #626 providing wound care to Resident #45 revealed RN #626 removed the residents wound dressing and there was no date documented on the dressing.Interview on 08/14/25 at Residents Affected - Few (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 5 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 08/14/2025 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)