GARDENS OF MCGREGOR AND AMASA STONE

Nursing Home Inspector

14900 PRIVATE DR
EAST CLEVELAND, OH 44112
Cuyahoga County
Phone: 216-851-8200
Provider Number: 366350
Last Inspection: 09/21/2017

About the Nursing Home

Number of Beds: 148
Number of Residents: 141
Beds Available: 7
Percent Occupancy: 95%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

15

Facility
11

County
15

OH
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

15

2017
0

2016
16

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/21/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 10/13/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 10/13/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 10/13/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/13/2017
 
Failed To: Provide or obtain dental services for each resident. Isolated : Minimal 3 10/13/2017
 

5/14/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 6/22/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 6/22/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 6/22/2015
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated : Minimal 3 6/22/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/22/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/29/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Immediate 5 8/29/2017
 

5/5/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 5/31/2017
 

12/29/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 1/14/2017
 

10/7/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/24/2016
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 10/24/2016
 

4/27/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/16/2016
 

10/16/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 11/10/2015
 

6/9/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 6/22/2015
 

6/2/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 6/22/2015
 

12/16/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 12/17/2014
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/17/2014
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Immediate 5 12/17/2014
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/17/2014
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg OH State Avg
Number of Residents 141 97.85 77.13
Registered Nurses 0.59 1.00 0.84
Licensed Practical / Vocational Nurses 1.07 0.90 0.92
Certified Nursing Assistants 2.64 2.31 2.24
Total Staff Hours 4.30 4.20 3.99

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% OH State Avg%
of high risk long-stay residents with pressure ulcers 9 6 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 92 95 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95 94 94
of long-stay residents experiencing one or more falls with major injury 6 3 3
of long-stay residents who have depressive symptoms 3 9 12
of long-stay residents who lose too much weight 14 7 7
of long-stay residents who received an antianxiety or hypnotic medication 6 16 24
of long-stay residents who received an antipsychotic medication 17 15 16
of long-stay residents who self-report moderate to severe pain 7 3 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 20 18 18
of long-stay residents whose need for help with daily activities has increased 17 15 15
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 1 2 3
of low risk long-stay residents who lose control of their bowels or bladder 85 44 42
of short-stay residents assessed and appropriately given the pneumococcal vaccine 75 84 86
of short-stay residents who had an outpatient emergency department visit 8 12 13
of short-stay residents who made improvements in function 57 63 65
of short-stay residents who newly received an antipsychotic medication 3 2 2
of short-stay residents who self-report moderate to severe pain 20 12 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 65 80 82
of short-stay residents who were rehospitalized after a nursing home admission 16 26 23
of short-stay residents who were successfully discharged to the community 60 52 57
of short-stay residents with pressure ulcers that are new or worsened 1 0 0