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Complaint Investigation

Cedarwood Plaza

October 14, 2025 · Cleveland Heights, OH · 12504 Cedar Road
Citations 6
CMS Rating 2/5
Beds 115
Provider ID 365033
Healthcare Facility
Cedarwood Plaza
Cleveland Heights, OH  ·  View full profile →
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.

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Inspection Findings

FF0690
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

SUMMARY STATEMENT OF DEFICIENCIES

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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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Plaza

12504 Cedar Road Cleveland Heights, OH 44106

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

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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