Cedarwood Plaza: Weight Loss Ignored Before ICU - OH
The woman, identified in inspection records only as Resident 104, was weighed on July 10, 2025, using a mechanical lift. That weight reflected a significant loss. Under the facility's own monitoring policy, a loss of five or more pounds was supposed to trigger a reweigh within 48 hours, and a dietitian was supposed to evaluate the result and order closer monitoring if the loss held. Neither happened in any timely way.
The corporate lead dietitian, brought in because the facility's regular dietitian was out on leave, confirmed it plainly during an interview with inspectors on October 9. The July weight loss, he said, had not been addressed in a timely manner.
By the time anyone formally documented the problem, the resident had already been to the hospital once. On August 12, she was sent out after experiencing seizure-like activity. She was admitted for bradycardia, altered mental status, and septic shock caused by a urinary tract infection. She didn't return to Cedarwood Plaza until August 26.
A nutrition assessment completed September 1, five days after she came back, put her weight at 138 pounds and confirmed the loss exceeded ten percent over the prior six months. The dietitian who completed that assessment recommended Magic cups, a calorie-and-protein supplement, twice a day, noting that she had refused other supplements in the past. A physician order for a nutritional treat twice daily was entered the same day.
Three days later, she was gone again.
A nurse practitioner note dated September 4 recorded that the resident had become lethargic and wasn't eating. Nursing was worried about sepsis. On September 5, progress notes confirmed she had been admitted to the hospital's intensive care unit for hypothermia.
The restorative certified nursing assistant who had weighed her in July told inspectors she understood that a loss of five or more pounds was supposed to result in weekly weights. She said the dietitian would be the one to make that call. The Director of Nursing said the same thing when inspectors interviewed her that afternoon. The dietitian reviewed all the weights, the DON explained, and would be the one to request closer monitoring. Then she acknowledged what the records had already shown: Resident 104 should have been put on weekly weights.
What the inspection doesn't say is who, if anyone, noticed the July weight and flagged it for the dietitian. The regular dietitian was out. The corporate lead dietitian confirmed the gap. The DON pointed at the dietitian. The restorative aide pointed at the dietitian. The system, as described by every person interviewed, depended entirely on one role, and that role was vacant.
Resident 104 was described in her Medicare assessment as cognitively intact. She was independent for eating, meaning she could feed herself. She had behavioral symptoms and a history of skipping meals, which the DON mentioned. The September nutrition note attributed the weight loss partly to decreased meal intake and behaviors. But skipping meals is not a surprise finding in a cognitively intact resident with a documented pattern of doing exactly that. It is the condition that monitoring is supposed to catch before it compounds.
She lost ten percent of her body weight. She went to the hospital twice in six weeks. The second time, she went to the ICU.
The inspection was completed October 14, 2025, following a complaint. Inspectors cited the facility for failing to ensure Resident 104 received adequate nutrition and monitoring, a deficiency classified as causing minimal harm or potential for actual harm. The facility's plan of correction was not included in the inspection record provided.
Resident 104's weight, as of her return from the hospital on August 26, was 138 pounds.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
CEDARWOOD PLAZA in CLEVELAND HEIGHTS, OH was cited for violations during a health inspection on October 14, 2025.
The woman, identified in inspection records only as Resident 104, was weighed on July 10, 2025, using a mechanical lift.
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.