Cedarwood Plaza: Catheter Care Failures Found - OH
The inspection, triggered by a formal complaint, found that the aide did not follow the facility's own written procedures for cleaning around the catheter insertion site, did not use a fresh section of washcloth with each stroke, and placed washcloths on an unclean overbed table before beginning care.
For residents with indwelling urinary catheters, the insertion site is a direct pathway into the body. Contaminating that site during care, by reusing a soiled portion of a washcloth or touching the area with unclean hands, can introduce bacteria directly into the urinary tract.
The aide's technique was not a close call. A registered nurse at the facility, identified in the inspection report as RN #398, confirmed during an interview on October 9 that the correct method for cleaning around the catheter of a male resident requires securing the catheter and cleaning in a circular motion from the inner area outward, using a clean part of the washcloth with each individual stroke. RN #398 also confirmed that hand hygiene is always required between glove changes, and that washcloths are never to be placed on an unclean overbed table before care begins.
The facility's own policy, last reviewed in January 2025, says the same thing. The hand hygiene policy states that gloves do not replace handwashing, and that staff must clean their hands before and after putting on or removing gloves, and after handling used linens or supplies. The catheter care policy requires that all debris be removed from around the insertion site, and specifies that if a resident has had an involuntary bowel movement, incontinence care must be completed before catheter care begins, so that fecal matter is not introduced to the catheter site.
The gap between what the policy says and what the aide did is what inspectors documented.
Cedarwood Plaza, located at 12504 Cedar Road in Cleveland Heights, received a citation under F0690, which covers the prevention of urinary tract infections and proper catheter care. Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
The citation does not say whether the resident developed an infection. It does not name the resident or the aide. What it records is that the procedure happened the way it happened, that a nurse at the facility confirmed it was wrong, and that the facility's written policies had been clear on every point the aide failed to follow.
Urinary tract infections are among the most common infections in nursing home residents with indwelling catheters. They can escalate quickly in older adults, moving from a localized infection to a bloodstream infection that requires hospitalization. The risk is not theoretical. It is why catheter care protocols exist in the detail they do, and why hand hygiene between glove changes is not optional.
The inspection report does not indicate how long the improper technique had been in use, whether this was an isolated incident or a pattern, or what the facility's plan of correction included. CMS directs residents and families to contact the facility or the state survey agency for that information.
What the record shows is a resident with an indwelling catheter, a procedure done wrong on at least one documented occasion, and a facility whose own nurse confirmed, point by point, exactly what should have happened instead.
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 25, 2026 · Our methodology
CEDARWOOD PLAZA in CLEVELAND HEIGHTS, OH was cited for violations during a health inspection on October 14, 2025.
For residents with indwelling urinary catheters, the insertion site is a direct pathway into the body.
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.