Cycle 1
Health 2025-08-14 · Fire 2025-08-14
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
East Cleveland, OH
Gardens Of Mcgregor And Amasa Stone
4-star overall rating with 4-star inspections with $15,651 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
14900 Private Dr, East Cleveland, OH
(216) 851-8200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
148
Certified beds
Average residents
136
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-06-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,579
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.63
Baseline 20.79% · Performance 19.75% · Measure score 3.63 · Achievement 3.63 · Improvement 2.26
Healthcare-associated infections
6.22
Baseline 5.96% · Performance 5.98% · Measure score 6.22 · Achievement 6.22 · Improvement 0
Total nurse turnover
3.43
Baseline 58.54% · Performance 49.66% · Measure score 3.43 · Achievement 3.43 · Improvement 2.14
Adjusted total nurse staffing
2.48
Baseline 3.81 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 77 · Observed rate 10.39% · Lower 95% interval 6.56% |
| Discharge to community | 62.12% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 77 · Observed rate 59.74% · Lower 95% interval 52.88% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 72.34% |
53.69%
18.7 pts better
|
Numerator 34 · Denominator 47 |
| Discharge mobility score | 27.66% |
50.94%
23.3 pts worse
|
Numerator 13 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 5.45% |
2.29%
3.2 pts worse
|
Numerator 3 · Denominator 55 · Adjusted rate 4.43% |
| Healthcare-associated infections requiring hospitalization | 5.98% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 1.82% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 3.78% |
8.2%
4.4 pts worse
|
Numerator 9 · Denominator 238 |
| Staff flu vaccination coverage | 6.72% |
42%
35.3 pts worse
|
Numerator 16 · Denominator 238 |
| Discharge function score | 36.17% |
56.45%
20.3 pts worse
|
Numerator 17 · Denominator 47 |
| Transfer of health information to provider | 93.94% |
95.95%
2 pts worse
|
Numerator 31 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 6 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
92.4%
7.2 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
94.5%
4.7 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.9% · Q4 1.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
26.1%
20 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.8% · Q3 6.1% · Q4 9.4% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
6.2%
4.4 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 0.0% · Q4 1.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
25.4%
13.1 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 12.5% · Q3 11.3% · Q4 13.5% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
11.5%
4.8 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 8.0% · Q3 6.6% · Q4 5.5% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
7.7%
5 pts worse
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 15.2% · Q3 14.7% · Q4 15.6% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
6.2%
1.6 pts worse
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.5% · Q3 10.0% · Q4 13.3% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.5%
0.8 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 1.8% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
21.7%
2.5 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 17.2% · Q3 23.1% · Q4 21.1% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
3.7%
1.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.9% · Q3 7.2% · Q4 5.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
78.1%
17.7 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 97.7% · Q3 97.3% · Q4 93.9% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
12.5%
0.2 pts better
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 11.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
75.6%
15.9 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
25.1%
0.2 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 22.2% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-12-12 · Fire 2019-12-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-08-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-08-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-08-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-08-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-08-29
F · Potential for more than minimal harm
2023-08-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-08-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-08-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-08-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-01
F · Potential for more than minimal harm
2019-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-21
F · Potential for more than minimal harm
2019-12-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-02-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-16
G · Actual harm
2023-08-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-08-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-01
B · Minimal harm
2023-08-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-08-23
D · Potential for more than minimal harm
2019-12-12
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2020-02-21
Penalties and ownership
What sits behind the stars
$15,651
2023-08-10
Fine
Fine · fine $15,651
Fine
Ownership
Althans, Susan
Corporate Officer · Individual
Balaji, Harigopal
Contracted Managing Employee · Individual
Boyd, Kanesha
Operational/Managerial Control · Individual
Boyd, Kanesha
W-2 Managing Employee · Individual
Bozman, Yuvette
Operational/Managerial Control · Individual
Bozman, Yuvette
W-2 Managing Employee · Individual
Conn, Ann
Corporate Officer · Individual
Conn, Ann
W-2 Managing Employee · Individual
Dallman, Deborah
Corporate Director · Individual
Gibbs, Donte
Corporate Director · Individual
Gladstone, Caroline
Corporate Director · Individual
Hardwick, Renee
Corporate Director · Individual
Haring, Andrew
Corporate Director · Individual
Hayes, Jennifer
Corporate Officer · Individual
Hayes, Jennifer
W-2 Managing Employee · Individual
Heintel, Christopher
Corporate Director · Individual
Kious Mcgovern, Lisa
Corporate Director · Individual
Knapp, Bradley
Corporate Director · Individual
Knapp, Bradley
Corporate Officer · Individual
Nagel, Katherine
Corporate Officer · Individual
Neiswander, Kirk
Corporate Director · Individual
Wilcoxson, Angela
Corporate Director · Individual
Wilcoxson, Angela
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Candlewood Healthcare And Rehabilitation
East Cleveland, OH
4-star overall rating with 3-star inspections with $29,488 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Eastbrook Healthcare Center
Cleveland, OH
2-star overall rating with 2-star inspections with $23,989 in total fines with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Hillside Plaza
Cleveland, OH
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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