Gardens Of Mcgregor And Amasa Stone

Review of Resident #34's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes and muscle weakness.Review of Resident #34's physician orders revealed an order dated 08/08/25 to use 5 milliliters (ml) of heparin and flush the peripherally inserted central catheter (PICC) line intravenously (IV) every 12 hours; an order dated 08/08/25 for vancomycin 1500 mg (milligrams)/300 ml with instructions to administer 500 ml IV one time a day for infection until 09/01/25; and an order dated 08/08/25 to use sodium chloride solution (normal saline or NS) 10 ml IV every 12 hours for a flush.Observation on 08/12/25 at 8:24 A.M. revealed Licensed Practical Nurse (LPN) #650 administered Resident #34's oral medications.

The nurse then washed her hands, put on gloves and flushed Resident #34's right arm PICC line with heparin solution, wiped the PICC hub and flushed with 10 ml of NS and then administered the IV vancomycin antibiotic via an administration pump.

Interview on 08/12/25 at 8:35 A.M. with LPN #650 revealed she was not aware that she was required to flush Resident #34's PICC line with the NS syringe, administer the IV antibiotic, flush the PICC a second time with NS and then use the heparin to maintain patency of the resident's PICC line.Interview on 08/12/25 at 9:40 A.M. with the Director of Nursing (DON) confirmed LPN #650 should have used best practice guidelines when administering Resident #34's IV antibiotic which included the SASH method (saline flush, administer medications, saline flush, heparin flush).

Review of the Flushing Considerations and Technique policy dated 2011 revealed for catheters requiring heparin use the S-A-S-H method which included to flush with saline prior to each use, administer the prescribed drug or infusion therapy, flush immediately afterward with saline and final flush with heparin to maintain patency during the time that the device was not in use.2.

Review of Resident #142's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, major depressive disorder and generalized anxiety disorder.Review of Resident #142's physician orders revealed an order dated 03/18/20 for cetirizine give 5 mg by mouth one time a day for allergies; and an order dated 12/15/22 for vitamin D3 50 MCG (micrograms) with instructions to administer one tablet by mouth one time a day for a supplement.Observation on 08/11/25 at 8:43 A.M. revealed LPN #668 administered eight medications to Resident #142 including cetirizine 10 mg and vitamin D3 25 mcg (1000 IU).Interview on 08/11/25 at 11:38 A.M. with LPN #668 confirmed she gave the wrong dose of cetirizine and vitamin D3 to Resident #142.

Review of the undated Medication Administration policy revealed the purpose was to ensure safe, accurate and timely administration of medications to residents in accordance with federal and state regulations, professional standards of practice, and facility procedures.This deficiency represents non-compliance investigated under Complaint Number 1280432.

366350 08/14/2025

Gardens of McGregor and Amasa Stone 14900 Private Dr East Cleveland, OH 44112

residents (#15, #36, #89, and #93) and had the potential to affect 131 residents who received meals

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.