Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Gardens Of Mcgregor And Amasa Stone during CMS and state inspections, most recent first.
Improper Storage of Resident Food and Beverages: Resident nourishment refrigerators and freezers on two units contained unlabeled food items and expired beverages, including takeout food, bacon, and ice cream with no resident identifiers or dates. The RD and DSGM verified the findings during observation.
A resident with a diabetic ulcer to the L lateral foot/malleolus did not receive ordered wound care as scheduled, and the TAR did not accurately reflect what was done. The resident reported missed daily treatments, an RN confirmed concerns about incomplete wound care, and an LPN later admitted documenting care that was not actually provided.
Medication administration errors exceeded the allowed rate after two residents were observed receiving medications incorrectly. One resident with a PICC line and IV vancomycin order was not flushed using the SASH method, and an LPN also gave another resident incorrect doses of cetirizine and vitamin D3. The DON confirmed the IV medication should have been given using best practice guidelines, and the LPN acknowledged the dose errors.
A resident with a history of pain was found on the floor and later reported a different kind of pain in her shoulder. Despite the recommendation for an x-ray, there was a delay in notifying the physician and obtaining the x-ray, which revealed a fracture. The delay in documentation and communication led to a delay in addressing the resident's change in condition.
Improper Storage of Resident Food and Beverages
Penalty
Summary
The facility failed to store food and beverages in a safe and sanitary manner in the resident nourishment refrigerators/freezers on the Two South and One South units. On the Two South unit, the resident nourishment refrigerator in the dining area contained a large brown bag of Olive Garden food with no resident name or date, and a half gallon of Minute Maid Fruit Punch that was expired as of 06/11/25. On the One South unit, the resident nourishment refrigerator in the dining room contained a white grocery bag with a pound of bacon that had no room number, resident name, or date, and the freezer contained a half quart of Butter Pecan ice cream and a half quart of Strawberry ice cream with no resident name or date received/opened. The Registered Dietitian and the Dietary Services General Manager verified the findings during the observations.
Missed wound care and inaccurate TAR documentation
Penalty
Summary
The facility failed to ensure Resident #45 received ordered wound care for a non-pressure related wound on the left lateral foot/lateral malleolus and failed to maintain accurate documentation of the treatments provided. The resident was admitted with diagnoses including cellulitis of the right lower limb, primary osteoarthritis of the knee, and essential hypertension. Physician orders directed cleansing the wound with normal saline, applying Santyl and calcium alginate, covering with a foam dressing, and later adding an ace wrap. The skin care plan included treatment per physician order, and a wound evaluation note described a diabetic ulcer measuring 1.2 cm by 2 cm with 100% slough at the base. The Treatment Administration Record showed wound care entries by an LPN on 08/03/25, 08/07/25, 08/08/25, and 08/11/25, but the resident stated she was not receiving wound care daily. She reported that after wound care on 08/07/25, she did not receive it again until 08/10/25 when she asked a day shift nurse to change the bandage because it was hurting. RN #626 confirmed the resident had raised concerns that wound care was not being completed daily and identified LPN #542 as the nurse not providing the wound care. LPN #542 later stated he documented wound care on 08/11/25 but got distracted and never provided it. During observation, RN #626 removed the resident's wound dressing and there was no date documented on the dressing, and RN #626 confirmed the TAR did not accurately reflect the wound care provided.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered and according to best practice guidelines, resulting in a medication error rate of 8.57% based on 35 medications administered with three errors. This affected two of five residents observed for medication administration. One resident had diagnoses including chronic obstructive pulmonary disease, diabetes, and muscle weakness and had physician orders for heparin flushes, normal saline flushes, and IV vancomycin through a PICC line. During observation, an LPN administered oral medications, then flushed the PICC line with heparin before administering the IV vancomycin, and then used normal saline, rather than following the SASH method. The LPN stated she was not aware she was required to flush with normal saline before and after the antibiotic and use heparin at the end, and the DON confirmed the SASH method should have been used. A second resident had diagnoses including unspecified dementia, major depressive disorder, and generalized anxiety disorder and had orders for cetirizine 5 mg daily and vitamin D3 50 mcg daily. During observation, an LPN administered cetirizine 10 mg and vitamin D3 25 mcg (1000 IU) instead of the ordered doses. The LPN later confirmed she gave the wrong dose of both medications. The facility’s medication administration policy stated medications were to be administered safely, accurately, and timely in accordance with regulations, professional standards, and facility procedures.
Delayed Response to Resident's Change in Condition
Penalty
Summary
The facility failed to provide timely care and services to a resident experiencing a change in condition. Resident #40, who had diagnoses including pain in the right hip, low back pain, and disorders of bone density, was found on the floor by a CNA. The resident was assessed by a nurse and reported no pain or head injury at the time. However, later, the resident reported to the social worker and ADON that she was experiencing a different kind of pain in her left shoulder, which was not documented in the medical record. An x-ray was recommended but not immediately ordered. The physician was not notified of the resident's new pain until the following day, and the x-ray was not ordered until late in the day. The x-ray results, which showed a nondisplaced distal clavicle fracture, were not obtained until the next day, delaying the resident's evaluation and treatment. The lack of timely documentation and communication with the physician contributed to the delay in addressing the resident's change in condition.
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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) |
|---|---|---|---|---|
| Candlewood Healthcare And Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Eastbrook Healthcare Center | 1.4 mi | ★★★★★ | 18 | 0 |
| Hillside Plaza | 1.9 mi | ★★★★★ | 1 | 0 |
| Willows Health And Rehab Ctr | 2.3 mi | ★★★★★ | 0 | 0 |
| Cedarwood Plaza | 2.4 mi | ★★★★★ | 8 | 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.