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Complaint Investigation

Cedarwood Plaza

October 14, 2025 · Cleveland Heights, OH · 12504 Cedar Road
Citations 6
CMS Rating 3/5
Beds 115
Provider ID 365033
Healthcare Facility
Cedarwood Plaza
Cleveland Heights, OH  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

CEDARWOOD PLAZA in CLEVELAND HEIGHTS, OH — inspection on October 14, 2025.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0690
Quality of Life and Care Deficiencies

Handwashing-Hand Hygiene, last reviewed on 01/06/25, revealed hand hygiene was to be performed

Care (Indwelling Catheter), dated 01/06/25, revealed staff were to clean the area well at the catheter

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.

365033 10/14/2025

Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

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.

365033 10/14/2025

Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

Observation of tray line on 10/08/25 from the beginning at 12:38 P.M. to the end at 1:27 P.M.

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.

365033 10/14/2025

Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

those preferences.

Interview on 10/08/25 at 3:11 P.M. with Resident #60 revealed lunch wasn't good

365033 10/14/2025

Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

Review of a professional kitchen equipment

the service report that parts were unavailable for the repair.

Interview on 10/15/25 at 12:09 P.M. with

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.

365033 10/14/2025

Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CLEVELAND HEIGHTS, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CEDARWOOD PLAZA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.