Cedarwood Plaza: Cardiac Diet Menu Violations - OH
The facility's fall and winter menu had spelled out the distinction clearly. For lunch that day, the general population would receive creamy mushroom chicken, a dish built around mushroom gravy. Residents on cardiac or two-gram sodium diets were supposed to get something different: one three-ounce chicken breast topped with sautéed mushrooms instead. The difference matters because sodium content in gravies and sauces is a primary concern for residents on cardiac and low-sodium therapeutic diets.
When inspectors checked the steam table at 11:48 a.m., before tray line even started, there were no sautéed mushrooms anywhere on it. The pan that was supposed to be there simply wasn't.
Tray line ran from 12:38 p.m. to 1:27 p.m. For nearly an hour, trays went out. Residents identified in the inspection report as Residents 9, 35, and 36 received mushroom gravy over their chicken. So did every other resident on those restricted diets, with one exception: an unidentified resident got brown gravy instead, because of a documented dislike or allergy to mushrooms.
A dietary staff member, identified in the report as Dietary staff number 311, confirmed it during tray line at 12:41 p.m. Everyone was getting mushroom gravy, she said, unless they had a dislike or allergy on file. Therapeutic diet restrictions apparently weren't part of the calculation.
The dietary consultant, number 650, confirmed afterward that no sautéed mushrooms had been served to residents on low-sodium or cardiac diets. When inspectors asked why, she said she would assume it was an error.
The facility's own undated policy manual said meals would be checked against the therapeutic diet spreadsheet before service to make sure foods matched what the menu required, and that each tray would be checked for accuracy. Neither check caught the missing sautéed mushrooms. Neither check stopped the trays from going out.
This violation, tagged F0803, was cited at a level of minimal harm or potential for actual harm, affecting some residents. It was investigated under a complaint, number 2618032, filed before inspectors arrived on October 14, 2025.
The harm classification of "minimal" reflects the regulatory framework's assessment, not necessarily the clinical stakes for any individual resident. Residents placed on two-gram sodium or cardiac diets are on them for a reason. A single meal is unlikely to cause a measurable health event. But the mechanism that failed here, the check against the therapeutic diet spreadsheet that the facility's own policy required, failed completely and without anyone noticing until trays were already in residents' hands.
For Residents 9, 35, and 36, and the others whose names don't appear in the report, lunch on October 8 arrived looking more or less like everyone else's. Chicken, noodles, a slice of creamy lemon pie. The difference between what they were supposed to receive and what they got wasn't visible on the plate.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedarwood Plaza from 2025-10-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
CEDARWOOD PLAZA in CLEVELAND HEIGHTS, OH was cited for violations during a health inspection on October 14, 2025.
The facility's fall and winter menu had spelled out the distinction clearly.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.