Gardens Of Mcgregor And Amasa Stone
Inspection Findings
F-Tag F0804
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and review of the facility policy, the facility failed to ensure palatable food and drink were served at a safe and appetizing temperature. This affected four residents (#15, #36, #89, and #93) and had the potential to affect 131 residents who received meals from the facility kitchen. The facility identified three residents who did not receive food from the kitchen (Resident #82, #128 and #78).
The facility census was 134. Findings include:Interview on 08/11/15 at 11:58 A.M. revealed Resident #15 stated the vegetables were cold and the meat was dry.Interview on 08/11/25 at 10:21 A.M. revealed Resident #36 stated the food was not good and the breakfast was always cold.Interview on 08/11/25 at 1:56 P.M. revealed Resident #89 stated the food was warm, but not hot, and was tasteless.Interview on 08/13/25 at 5:00 P.M. with Resident #93's daughter stated she needed to bring outside food for her father because her father did not like the taste of the facility food.Observation on 08/12/25 at 11:00 A.M. revealed
the holding temperatures of the food items on the tray line. The pasta with vegetables and tomato sauce was 199.2 degrees Fahrenheit (F.), the coffee was 143.9 degrees F., and milk was 39.7 degrees F. A test tray was prepared which included the pasta with vegetables, milk, and coffee and the test tray left the kitchen on 08/12/25 at 12:44 P.M. The test tray reached the Two South Unit at 12:44 P.M. Nursing staff started to pass the trays on 08/12/25 at 12:54 P.M. with the last tray passed at 1:17 P.M. Registered Dietitian (RD) #735 used a calibrated facility thermometer to obtain the test tray food temperatures. The test tray temperatures revealed the coffee was 124.3 degrees F., the two percent milk (one pint carton) was 56.8 degrees F., and the pasta with vegetables and tomato sauce was 115.0 degrees F. The mildness was not palatable, and it was warm to the taste. RD #735 verified the pasta with vegetables and tomato sauce was not palatable and did not taste warm.Review of facility policy titled Taste and Temperature Control, revised May 2025, revealed food was maintained at palatable temperatures during service to meet resident expectations.This deficiency represents non-compliance investigated under Complaint Number 1280432.
Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
GARDENS OF MCGREGOR AND AMASA STONE in EAST CLEVELAND, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EAST CLEVELAND, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GARDENS OF MCGREGOR AND AMASA STONE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.