Gardens of Mcgregor and Amasa Stone

In the surveyor’s words

From the most serious findings on record at Gardens of Mcgregor and Amasa Stone, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 10, 2023

  Based on observation, record review, hospital record review and interview the facility failed to provide adequate supervision and intervention to prevent and mitigate a fall with injury for Resident #30. Actual harm occurred on 06/08/23 when Resident #30, who required the assistance of two staff for bed mobility, fell from a bed in high position when receiving incontinence care by one staff member resulting in a right hip dislocation and hospitalization . This affected one resident (#30) of two residents reviewed for accident hazards. The total census was 135. Findings include: Record review for Resident #30 revealed the resident was admitted to the facility 10/11/21 and had diagnoses including cognitive communication deficit, osteoarthritis, and anxiety disorder. […]

• Actual harm, isolatedF689Apr 21, 2022

  Based on record review and interview the facility failed to ensure Resident #120, who required a mechanical lift (Hoyer lift) for transfers was transferred in a safe manner to prevent injury. Actual harm occurred on 04/04/22 when two staff manually transferred Resident #120 from the wheelchair to the bed, using only his arms and legs, resulting in a fracture of his upper right femur (thigh bone)/hip. Resident #120 was admitted to the hospital and required surgical repair of his fracture. This affected one of three residents reviewed for accidents. […]

• No harm, potential for more than minimal, widespreadF880Feb 3, 2022

  Based on observation, interview, record review and policy review, the facility failed to accurately communicate with appropriate signage residents on droplet isolation precautions, don appropriate personal protective equipment (PPE) prior to entering a resident's room on droplet isolation precautions or change their N95 mask, cleanse their goggles or face shields, or perform hand hygiene after exiting a resident's room on droplet isolation precautions. This affected three (Resident's #23, #25 and #58) of three residents on respiratory droplet isolation precautions and had the potential to affect all 126 residents residing in the facility. Findings include: Observation during the tour of the facility on 01/31/22 from 7:54 A.M. to 8:02 A.M. […]

• No harm, potential for more than minimal, widespreadF880Feb 23, 2021

  Based on observations, staff interview, review of the facility's Coronavirus (COVID-19) in-service, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH (revised 3/13/20), review of the World Health Organization (WHO) hand hygiene brochure, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement appropriate and recommended infection control practices by not ensuring appropriate use of Personal Protective Equipment (PPE) for residents' on COVID-19 quarantine precautions by not ensuring the use of N95 and KN95 respirators, face shields, goggles, and proper hand hygiene was consistently implemented to potentially prevent the spread of COVID-19 infections. […]

• No harm, potential for more than minimal, patternF804Aug 14, 2025

  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. […]