Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Candlewood Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident’s fund account was not dispersed timely after discharge. The resident had diagnoses including unspecified dementia, paranoid schizophrenia, and major depressive disorder, and $767.94 was not released within the required 30-day timeframe. The RDO confirmed the delay.
Cross Contamination During Tracheostomy Care: An RN provided trach care to a resident with a trach and chronic respiratory failure but did not maintain sterile technique. After removing the soiled inner cannula and dressing, she inserted a new sterile inner cannula and applied a new trach sponge while still wearing the same gloves, and both the RN and an LPN verified the infection control lapse.
A resident with a history of aggressive behavior physically assaulted two other residents, causing significant harm. The facility failed to implement individualized interventions or adequately document supervision, resulting in unprovoked attacks. Despite policies requiring increased supervision and care plan revisions, these measures were not effectively executed.
A resident with multiple behavioral health diagnoses exhibited unprovoked aggression towards other residents. Despite being on a medication regimen and having a history of aggression, the facility failed to create an individualized care plan, resulting in repeated incidents. Staff were unaware of specific interventions beyond routine checks, and the care plan remained generalized, lacking tailored strategies to manage the resident's behaviors.
A resident with multiple medical conditions reported an abuse incident involving a staff member, which was not communicated to the Administrator as required by facility policy. Despite the resident and an STNA reporting the incident to a former RN, the facility's leadership remained unaware of the allegation, leading to a deficiency citation.
Delayed Disbursement of Resident Funds After Discharge
Penalty
Summary
The facility failed to ensure Resident #96’s resident fund account was dispersed timely after discharge from the facility. Resident #96 had been readmitted on [DATE] and was discharged on 06/06/25 with diagnoses including unspecified dementia, paranoid schizophrenia, and major depressive disorder. Review of the resident fund account showed that $767.94 was dispersed on 07/29/25, following the resident’s discharge. During an interview on 07/30/25 at 12:18 P.M., the Regional Director of Operations confirmed that the resident fund monies were not dispersed within thirty days as required.
Cross Contamination During Tracheostomy Care
Penalty
Summary
Failure to provide safe and appropriate respiratory care occurred during tracheostomy care for one resident with diagnoses including brain damage, tracheostomy status, and chronic respiratory failure. The resident had physician orders for daily inner cannula changes and tracheostomy tie changes every night shift and as needed. During an observation of tracheostomy care, the RN washed hands, donned a surgical mask, gown, and gloves, and prepared the resident and supplies for care. She removed and replaced the tracheostomy ties, then removed the split tracheostomy gauze sponge and inner cannula and placed them on the barrier on the resident’s chest. Without removing the soiled gloves or washing her hands and applying clean gloves, the RN went to the tray table, removed a new sterile cannula from its package, and inserted it into the outer cannula while wearing the same gloves used during the prior treatment steps. She then opened a new split tracheostomy sponge and placed it around the tracheostomy and reapplied the oxygen mask while still wearing the same gloves. The RN and the ADON/LPN present both verified that proper steps were not followed during tracheostomy care and that infection control practices were not maintained to prevent cross contamination. The facility policy required sterile technique for changing the inner cannula, trach dressing, and collar.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in actual harm. Resident #93 was physically assaulted by Resident #50, who punched him in the head without provocation, causing significant pain and a nondisplaced right occipital bone fracture. This incident led to Resident #93 being transferred to a hospital for further evaluation and treatment. Prior to this incident, Resident #50 had a documented history of abusive behavior towards other residents. Resident #64 was also a victim of physical abuse by Resident #50. After finishing dinner, Resident #64 was struck in the face by Resident #50, causing him to fall to the floor and sustain a swollen lip. This incident was witnessed by staff, and Resident #50 was subsequently sent to the hospital for a psychiatric evaluation. Despite these incidents, the facility's interventions for Resident #50 were generalized and not individualized, failing to adequately protect other residents from his aggressive behavior. The facility's documentation and supervision of Resident #50 were insufficient. Although every 15-minute checks were supposed to be in place for Resident #50, there was no evidence provided that these checks were consistently completed. Interviews with staff revealed a lack of awareness of specific interventions to manage Resident #50's impulsive behaviors, aside from the 15-minute checks. The facility's policy required increased supervision and care plan revisions in such cases, but these measures were not effectively implemented.
Failure to Individualize Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop an individualized care plan for Resident #50, who had multiple behavioral health diagnoses including major depressive disorder, schizophrenia, and generalized anxiety disorder. Despite being cognitively intact, Resident #50 exhibited hallucinations, delusions, and wandering behaviors. The resident was on a medication regimen that included Aripiprazole, Clonazepam, and Fluvoxamine Maleate, and was reported to be at baseline with no behavioral issues according to a psychiatric nurse practitioner. However, incidents of physical aggression occurred, including an unprovoked attack on another resident, Resident #64, which resulted in a swollen lip for the latter. Following the first incident, Resident #50 was placed on one-to-one supervision and sent for a psychiatric evaluation, but returned with no new orders. The care plan developed post-incident was generalized and not tailored to the specific needs of Resident #50, failing to address the resident's poor impulse control and history of aggression. A subsequent incident occurred where Resident #50 again attacked another resident, Resident #93, without provocation, leading to another hospital evaluation. The care plan remained non-individualized, with interventions that were not specific to Resident #50's behavioral triggers or needs. Interviews with staff, including registered nurses and state-tested nurse aides, revealed a lack of awareness of any additional interventions beyond 15-minute checks. The Director of Nursing and other administrative staff were unable to specify expectations for increased supervision or individualized care strategies. Despite repeated aggressive incidents, the facility did not implement a care plan with specific interventions to manage Resident #50's behaviors, leading to continued unprovoked assaults on other residents.
Failure to Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report a staff-to-resident physical abuse allegation involving a resident to the Administrator. The resident, who had a history of cerebral infarction, hemiplegia, vascular dementia, and other medical conditions, reported that a staff member bent his arm back and cut his fingernails against his wishes. This incident reportedly occurred approximately four months prior to the survey, and the resident claimed to have informed a nurse or another staff member, though he could not recall the name. An STNA confirmed that the resident had made an abuse allegation against another STNA, stating that the staff member pulled his arm despite his protests. This information was reportedly passed to a former RN who had not worked at the facility since February of the same year. Interviews with the facility's Administrator, DON, and other staff revealed that they were unaware of the abuse allegation. The resident's POA also reported rough treatment by the same STNA to other staff members, but could not remember their names. The facility's policy requires immediate reporting of abuse allegations to the Administrator or designee, which did not occur in this case. The failure to report the incident as per the facility's policy led to the deficiency being cited during the investigation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens Of Mcgregor And Amasa Stone | 0.7 mi | ★★★★★ | 20 | 0 |
| Cedarwood Plaza | 1.8 mi | ★★★★★ | 8 | 0 |
| Eastbrook Healthcare Center | 2.1 mi | ★★★★★ | 18 | 0 |
| Judson Park | 2.3 mi | ★★★★★ | 0 | 0 |
| University Manor Health & Reha | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.