Gardens of McGregor: Wound Care Documentation Failures - OH
At Gardens of McGregor and Amasa Stone, a 14900 Private Drive nursing facility in East Cleveland, inspectors found that wound care documentation did not accurately reflect the treatment residents actually received. That finding didn't come from a routine sweep. It came from a complaint, filed under Complaint Number 1280432, that prompted the August 2025 inspection.
RN #626 confirmed it directly: the Treatment Administration Record, the document that is supposed to capture what wound care was provided and when, did not match reality.
That kind of gap matters in a nursing home. Wound care is one of the most time-sensitive interventions in long-term care. Pressure wounds can progress from minor skin breakdown to deep tissue destruction in days. The record of what was done, and when, is how nurses track whether a wound is improving or worsening, whether interventions are working, and what the physician or nurse practitioner needs to know to adjust the plan. When that record is wrong, the clinical picture is wrong.
The facility's own policy, dated January 2024, stated that care plans would be developed and updated as needed, and that interventions would be implemented based on physician or nurse practitioner guidance and the judgment of the interdisciplinary team. Whether any of that happened correctly for the residents involved, inspectors could not determine from the records alone. That was the problem.
The nurse who confirmed the documentation failure, RN #626, was not new to the issue. A supervisor told inspectors she had spoken with RN #626 before August 7, 2025, about correct documentation practices, and again on August 7. The inspection was completed August 14. The conversations about documentation accuracy predated the inspection by at least a week, suggesting the facility was aware of a problem before inspectors arrived.
Inspectors classified the harm level as minimal, with potential for actual harm, and noted that few residents were affected. Those qualifiers carry weight in the federal deficiency framework, but they also carry limits. "Minimal harm" describes what inspectors could document. It does not describe what might have gone undetected in records that, by the facility's own nurse's admission, were not accurate.
The deficiency was cited under the skin alteration and pressure injury prevention standard, a category that covers one of the most common and preventable sources of suffering in nursing home residents. Pressure injuries are painful. They are slow to heal. In residents with limited mobility, compromised circulation, or diabetes, they can become life-threatening. The residents at Gardens of McGregor who received wound care during this period were relying on staff to document what was done so that the next shift, the next nurse, the next physician visit could build on accurate information.
The records they left behind were not accurate. The facility's own nurse said so.
Gardens of McGregor and Amasa Stone serves residents in a part of East Cleveland where access to alternative long-term care options is limited. The facility's plan of correction was not included in the inspection materials reviewed for this article. For information on what the facility intends to do, CMS directs the public to contact the nursing home or the Ohio state survey agency directly.
What the inspection record does not resolve is simpler and harder: for the residents whose wound care was not accurately documented during this period, there is no way to reconstruct what actually happened to them, or whether what happened was enough.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
That finding didn't come from a routine sweep.
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.