The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited August 2023 — isolated incident, actual harm.
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F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
GARDENS OF MCGREGOR AND AMASA STONE
EAST CLEVELAND, OH · Medicare-certified · 148 beds
In good standing
Non-profit
4 of 5 overall
4/5 overall. Strong health inspection and quality scores, no fines in the last 24 months, but staffing is very low at 1/5; recent inspection citations included accident hazards/supervision and food safety/temperature issues.
Facility ratings
Health inspections
Staffing
Quality measures
Last inspection: August 14, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports not reported.
Staffing detail
Total staff turnover: 75%
Registered nurse turnover: 63%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
7%Steady
Residents with a fall causing major injury
1.5%Steady
Residents with pressure ulcers (bedsores)
5.5%Improving
Residents with a urinary tract infection
1.1%Improving
Residents who lost too much weight
2.1%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
12.1%Worsening
Residents whose ability to walk got worse
13.6%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
12.1%Improving
Short-stay residents newly given an antipsychotic
0.5%Worsening
Residents with a long-term catheter
0.2%Worsening
Residents with new or worsening incontinence
20.1%Worsening
Residents with depressive symptoms
7.3%Worsening
Long-stay residents given the seasonal flu vaccine
99.2%Steady
Long-stay residents given the pneumonia vaccine
99.8%Steady
Short-stay residents given the seasonal flu vaccine
91.5%Steady
Short-stay residents given the pneumonia vaccine
94.8%Worsening
What the inspectors found
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited August 2025 — limited pattern, potential for harm.
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F-Tag 812 — 42 CFR §483.60(i) — S/S: E
The home failed to make food and drinks appealing and served them at a safe, appetizing temperature. Cited August 2025 — limited pattern, potential for harm.
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F-Tag 804 — 42 CFR §483.60 — S/S: E
The home failed to ensure a licensed pharmacist reviewed residents' medications each month and reported any problems as required. Cited August 2023 — limited pattern, potential for harm.
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F-Tag 756 — 42 CFR §483.45(c) — S/S: E
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited August 2025 — isolated incident, potential for harm.
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F-Tag 684 — 42 CFR §483.25 — S/S: D
Recent history
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $15,651 in total fines.
- $15,651
Federal fine
Aug 10, 2023
Operator & ownership
- Ownership
- Non profit - Other
- Occupancy
- 137.3 residents on an average day (93% of 148 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 19 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.