Gardens of McGregor: Medication Errors at 8.57% Rate - OH
That was one of three medication errors inspectors documented during a single observation window at the facility in August, producing an error rate of 8.57 percent across 35 administered doses.
The resident who received the wrong doses, identified in inspection records only as Resident 142, had been living at the facility with unspecified dementia, major depressive disorder, and generalized anxiety disorder. Her physician had ordered cetirizine at 5 milligrams once daily for allergies, a dose on the books since March 2020. Her vitamin D3 order called for 50 micrograms once daily, written in December 2022. On the morning of August 11, LPN 668 gave her 10 milligrams of cetirizine and only 25 micrograms of vitamin D3. When inspectors spoke with LPN 668 that afternoon, she confirmed both errors.
The second nurse involved didn't know a required procedure existed.
Resident 34, who had been admitted and readmitted with chronic obstructive pulmonary disease, diabetes, and muscle weakness, was receiving intravenous vancomycin, a powerful antibiotic, through a peripherally inserted central catheter in his right arm. A PICC line runs from a vein in the arm directly toward the heart, and flushing it correctly before and after an IV infusion keeps the line clear and prevents infection. The facility's own policy, written in 2011, spelled out the required sequence: flush with saline before use, administer the medication, flush again with saline immediately afterward, then finish with heparin to keep the line open between uses. The method is known in nursing practice as SASH.
On the morning of August 12, inspectors watched LPN 650 approach Resident 34's PICC line. She flushed it first with heparin, wiped the hub, flushed with 10 milliliters of saline, and then started the vancomycin infusion. The required second saline flush after the antibiotic and the correct ordering of the sequence were both absent.
When inspectors spoke with LPN 650 eleven minutes after the administration, she told them she was not aware she was required to flush with saline first, then administer the antibiotic, then flush with saline again, and then use the heparin. The Director of Nursing, interviewed later that morning, confirmed LPN 650 should have followed the SASH method and that she had not.
The vancomycin order for Resident 34 had been written August 8 and was set to run through September 1. The heparin flush order and the saline flush order were both written the same day.
The inspection was conducted August 14 and was triggered in part by a complaint, logged under complaint number 1280432. Inspectors assessed the level of harm as minimal, a designation that reflects the absence of documented injury, not the absence of risk.
A PICC line that is not flushed in the correct sequence can clot, rendering the line unusable and requiring replacement. More seriously, improper technique around a central catheter creates conditions for bloodstream infection, a complication that carries a significant mortality risk in elderly patients, particularly those already fighting an active infection serious enough to require IV antibiotics. The inspection report does not document whether Resident 34 experienced any complications.
Resident 142's dementia means she was not in a position to notice or report that her medications looked different than usual. The inspection report does not indicate anyone else flagged the discrepancy before inspectors arrived.
LPN 650 had been administering vancomycin to Resident 34 without knowing the required flush protocol. The inspection record does not say how many times she had done so before August 12.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens of Mcgregor and Amasa Stone from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 19, 2026 · Our methodology
GARDENS OF MCGREGOR AND AMASA STONE in EAST CLEVELAND, OH was cited for violations during a health inspection on August 14, 2025.
Her physician had ordered cetirizine at 5 milligrams once daily for allergies, a dose on the books since March 2020.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.