Cedarwood Plaza

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

basins and clean washcloths were to be used for catheter care and that staff were never to use the same part of the washcloth for cleaning around the catheter insertion site, catheter, or other body parts during catheter and perineal care. Interview on 10/09/25 at 2:40 P.M. with Registered Nurse (RN) #398 confirmed staff were to clean the urinary meatus of a male with an indwelling catheter by securing the catheter and cleaning in a circular motion from inner to outer areas, using a clean part of the washcloth with each stroke, and care should be taken to ensure cleanliness of the catheter near the insertion site. RN #398 further confirmed that staff were to use a barrier or a wash basin and not lay washcloths on an unclean overbed table before commencing care. RN #398 also confirmed hand hygiene was always to be performed between glove changes. Review of the policy titled Handwashing-Hand Hygiene, last reviewed on 01/06/25, revealed hand hygiene was to be performed before and after donning and doffing gloves and after handling used linens or supplies. The policy further revealed the use of gloves did not replace hand hygiene. Review of the policy titled Catheter Care (Indwelling Catheter), dated 01/06/25, revealed staff were to clean the area well at the catheter insertion site and that all debris was to be removed from around the catheter, near

the insertion site. Further review of the policy revealed if the resident was soiled or had an involuntary bowel movement, the incontinence care should be provided prior to catheter care to ensure the area was not contaminated with feces. This deficiency represents noncompliance investigated under Complaint Number 2623950.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

revealed an order dated 08/04/25 for Ensure twice a day. Continued review of Resident #104's medical

record revealed the resident was not weighed again until 08/07/25 when the resident weighed 139 pounds, which reflected a seven pound or 4.7% additional weight loss from the 07/10/25 weight. Weights of 139 pounds on 08/11/25 and 138 on 08/26/25 revealed weight loss appeared to have stabilized. Further review of Resident #104's medical record revealed the resident had a seizure like activity on 08/12/25 and was sent to the hospital and was admitted for bradycardia, seizure like activity, altered mental status, and septic shock due to a urinary tract infection (UTI). The resident didn't readmit back to the facility until 08/26/25. The Ensure order was discontinued on 08/12/25 when the resident was admitted to the hospital. Review of Resident #104's five-day Medicare MDS 3.0 assessment dated [DATE REDACTED] revealed the resident was cognitively intact, exhibited other behavioral symptoms not directed toward others, was independent for eating, had a significant weight loss which had not been prescribed and was not on any therapeutic diet.

Continued review of Resident #104's medical record revealed a readmission nutrition assessment, dated 09/01/25, which indicated the resident's most recent weight was 138 pounds on 08/26/25 which reflected a significant loss of ten percent or greater over the past six months, which was likely related to decreased meal intakes and behaviors. It was recommended that Magic cups (supplement) be added twice a day to increase caloric and protein intake to help promote weight stability, and it was noted other supplements had been refused by the resident in the past. Further review of Resident #104's physician orders revealed an order dated 09/01/25 for a nutritional treat two times a day. Continued review of Resident #104's medical

record revealed a nurse practitioner note dated 09/04/25 which indicated the resident had become lethargic and nursing was reporting the resident wasn't eating well and was being sent to the hospital due to concern of sepsis. On 09/05/25 it was noted in the progress notes that the resident had been admitted to the hospital's intensive care unit for hypothermia. Interview on 10/09/25 at 11:28 A.M. with Restorative Certified Nursing Assistant (CNA) #440 revealed restorative staff were responsible for obtaining most of the weights.

She stated she had weighed Resident #104 on 07/10/25 and had used a Hoyer (mechanical lift) to weigh her. She stated typically when a resident lost five or more pounds a resident would be put on weekly weights for closer monitoring. She indicated the dietitian would be the one who would indicate if a resident should be put on weekly weights. Interviews on 10/09/25 at 11:54 A.M. and 12:30 P.M. with Corporate Lead Dietitian (CLD) #651 revealed the current facility dietitian was currently out on leave of absence. He stated if

a monthly weight triggered a significant weight loss of five % or more, a reweight would be obtained. If the reweight still showed a significant weight loss, the dietitian would address the weight loss in a note or an assessment and normally the resident would be put on weekly weights for closer monitoring. LCD #651 confirmed Resident #104's weight loss on 07/10/25 had not been addressed in a timely manner by the dietitian. Interview on 10/09/25 at 2:10 P.M. with the Director of Nursing (DON) revealed the dietitian reviewed all the weights and would be the one who requested a resident be put on weekly weights for closer monitoring. She acknowledged Resident #104's weight loss and stated the resident would skip meals. The DON indicated Resident #104 should have been put on weekly weights for closer monitoring.

Review of facility policy Weight Monitoring, with a last review date of 01/06/25, revealed reweights would be obtained within 48 hours if there was at least a five-pound deviation from the last weight obtained. The dietitian would evaluate weights and initiate appropriate interventions as indicated and would follow up with nursing to confirm that reweights had been completed and the requested orders had been obtained. This deficiency represents non-compliance under Complaint Number 2623950.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

adequacy and tolerance. 4. Review of the facility's week four fall and winter menu for 2024 and 2025 revealed for lunch on 10/08/25 creamy mushroom chicken, herb buttered noodles, zucchini and onion, and creamy lemon pie was to be served. Review of the facility's four week fall and winter menu's spread sheet for lunch on day 25 (10/08/25) revealed residents on a cardiac diet or a two-gram (low sodium) diet were to receive one three-ounce chicken breast with sauteed mushrooms instead of one three-ounce chicken breast with mushroom gravy. Observation of the steam table on 10/08/25 prior to the start of tray line at 11:48 A.M. revealed there was no pan of sauteed mushrooms in the steam table. Observation of tray line on 10/08/25 from the beginning at 12:38 P.M. to the end at 1:27 P.M. revealed all residents, which included Residents #9, #35, and #36, had received mushroom gravy over their chicken, except for one unidentified resident who had received brown gravy over the chicken due to either a dislike or an allergy to mushroom gravy. Interview during tray line on 01/08/25 at 12:41 P.M. with Dietary [NAME] #311 confirmed everyone was receiving mushroom gravy over the chicken, unless it was a dislike or an allergy. Interview on 10/08/25 at 1:28 P.M. with Dietary Consultant #650 confirmed no sauteed mushrooms had been served to residents

on a two-gram sodium (low salt) or a cardiac diet. When asked why residents who were on a two-gram sodium (low sodium) or cardiac diet had not been served sauteed mushrooms on their chicken instead of mushroom gravy, DC #650 stated I would assume it was an error. Review of the undated facility policy Accuracy and Procedure Manual revealed the meal would be checked against the therapeutic diet spread sheet to assure that foods were served as listed on the menu, and each meal tray would be checked for accuracy following the therapeutic extension. This deficiency represents non-compliance investigated under Complaint Number 2618032.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

without bleeding, acute kidney failure, malignant neoplasm of the pancreas, and temporomandibular joint disorder. Review of the diet order dated 11/25/24 revealed Resident #60 was prescribed a regular diet with regular consistency and thin fluid consistency. Review of the quarterly MDS 3.0 assessment completed on 07/10/25 revealed Resident #60 had moderately impaired cognition and needed setup or clean-up assistance with eating. Further review of the MDS revealed Resident #60 was not on a prescribed therapeutic diet. Review of the care plan last completed 07/17/25 revealed Resident #60 had the potential for altered nutrition secondary to advanced age, cancer, diabetes mellitus, malnutrition, and decrease in oral intake. Interventions included discussion with Resident #60 to identify any cultural, ethnic, religious, or other food preferences and to accommodate for, and honor, those preferences. Interview on 10/08/25 at 3:11 P.M. with Resident #60 revealed lunch wasn't good today. Food was blah, and the food could have been warmer. This deficiency represents non-compliance investigated under Complaint Number 2618032.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

135 degrees F., and the tray line and service areas would avoid holding food in the danger zone (41 degrees F to 135 degrees). Review of a professional kitchen equipment supplier/repair company Repair Estimate Summary, dated 10/01/25, revealed the heating elements and thermostat needed replaced for the steam table to be functional. There was no indication noted on the Repair Estimate Summary that parts were unavailable for the repair or the facility had okayed the repair. Review of a professional kitchen equipment supplier/repair company invoice, dated 10/09/25, revealed the steamer was able to be repaired

the same day as the service call by replacing the hose with a PVC pipe. There was no indication noted in

the service report that parts were unavailable for the repair. Interview on 10/15/25 at 12:09 P.M. with Representative #675 from the professional kitchen equipment supplier/repair company revealed the request to repair the steamer had not been called in by the facility until 10/08/25 at 3:05 P.M. This deficiency was an incidental finding identified at the time of the complaint survey.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

were supposed to be removed prior to exiting the room. At the time of the interview, CNA #413 confirmed leaving Resident #6's room between catheter care and incontinence care and that only one glove was removed at that time, staff were not to be in the hall with soiled gloves, and no hand hygiene was performed

before donning a clean glove. Interview on 10/09/25 at 9:55 A.M. with CNA #383 confirmed basins and clean washcloths were to be used for washing residents and that staff were never to use the same part of

the washcloth for cleaning around the catheter insertion site, catheter, and other body parts during catheter and perineal care. Interview on 10/09/25 at 10:33 A.M. with CNA #390 confirmed staff were to make sure two bags were ready for linen and trash disposal prior to rendering perineal or catheter care and that soiled items were never to be placed on the floor. During the interview, CNA #390 reported PPE was to always be removed prior to exiting resident rooms. Interview on 10/09/25 at 2:40 P.M. with Registered Nurse (RN) #398 confirmed staff were to clean the urinary meatus of a male with an indwelling catheter by securing the catheter and cleaning in a circular motion from inner to outer areas, using a clean part of the washcloth with each stroke, and care should be taken to ensure cleanliness of the catheter near the insertion site. RN #398 further confirmed that staff were to use a barrier or a wash basin and not lay washcloths on an unclean overbed table before commencing care. During the interview, RN #398 stated two bags were to be readily available during care, one for soiled disposable items and one for soiled linen, and that PPE was to be removed after care, prior to leaving a resident's room. RN #398 also confirmed hand hygiene was always to be performed with glove changes. Review of the policy titled Handwashing-Hand Hygiene, last reviewed on 01/06/25, revealed hand hygiene was to be performed before and after donning and doffing gloves and after handling used linens or supplies. The policy further revealed the use of gloves did not replace hand hygiene. Review of the policy titled Enhanced Barrier Precautions, dated 01/06/25, revealed PPE was to be removed and placed in a receptacle inside the resident room after resident care activities were completed. Review of the policy titled Catheter Care (Indwelling Catheter), dated 01/06/25, revealed staff were to clean the area well at the catheter insertion site and that all debris was to be removed from around the catheter, near the insertion site. Further review of the policy revealed if the resident was soiled or had an involuntary bowel movement, the incontinence care should be provided prior to catheter care to ensure they are not contaminated with feces. Review of the policy titled Incontinence Care, last reviewed 11/30/25, revealed soiled linen was to be disposed of appropriately. This deficiency represents noncompliance investigated under Complaint Number 2618032.

Event ID:

Facility ID:

If continuation sheet