Health inspection·July 1, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, and interviews, the facility failed to ensure the correct serving sizes and all menu items were provided per the menu. This affected four residents (#28, #43, #55, and #99) but had the potential to affect all residents, except two residents (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Interviews on 07/01/25 between 9:44 A.M. and 1:18 P.M. with Residents #28, #55, and #99 revealed they received small portions at mealtimes, but also stated they never knew what was on the menu prior to receiving meals. Review of the menu revealed lunch for 07/01/25 was deli meat and cheese sandwich, creamy coleslaw, and four ounces (oz) of cinnamon apple slices. Residents on a pureed diet were to get pureed soft, cooked vegetables servings size was #12 scoop (green handle which provides a 2.7 oz portion) and pureed cinnamon apple slice serving size was a #10 scoop (three oz). Residents on a mechanical soft diet were to receive ground deli meat and cheese using a #8 scoop (four oz). Observations on 07/01/25 between 12:20 P.M. and 12:45 P.M. of the lunch tray line revealed a large pan of sliced deli meat sitting on the steam table (not in an ice bath), next to it was a large pan of lettuce, and a large pan of sliced tomatoes. [NAME] #555 tore open a loaf of white bread while wearing gloved hands, grabbed slices of bread, grabbed two slices of deli meat, folded it over onto the bread and proceeded to grab lettuce and tomato slices and place onto one slice of bread and then place the second slice of bread on top all while using the same gloved hands. Further observation revealed [NAME] #555 made a pureed plate serving mixed vegetables using a purple handled scoop #40 (providing 0.75 oz. serving). Observation of the mechanical soft diet being plated revealed [NAME] #555 plated ground turkey using a green handled scoop #12 (providing a 2.7 oz. portion) and placed the ground meat between two slices of bread. Observation at the end of the tray line revealed two additional pans. In one pan were several two oz. plastic containers of applesauce, and in the second pan next to it were several two oz. plastic containers of cottage cheese and pineapples tidbits. Interview on 07/01/25 between 12:20 P.M. and 12:45 P.M. with Dietary Manager (DM) #648 they had to swap out the coleslaw and provide chips instead, and also had to provide cottage cheese with fruit and applesauce cups instead of apple slices. DM #648 verified there was no cheese for the deli sandwiches and that the plastic containers were two ounce servings instead of the four ounce servings for the fruit. DM #648 also verified the scoop serving for the pureed veggies and mechanical meat were not correct as well and residents were served smaller portions than what was listed on the menu. Page 1 of 3 365033 365033 07/01/2025 Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 07/01/25 at 1:04 P.M. of Resident #43's lunch revealed two sandwiches, bag of chips, and a two ounce serving of pineapples. Interview at the time of observation with Resident #43 revealed portion sizes for the fruit cups and cottage cheese were usually in the two ounce containers. Resident #43 stated they don't get or see a menu to know what they will receive for meals. Observation on 07/01/25 at 1:23 P.M. of Resident #55 and #99's lunches revealed both had sandwiches and potato chips but did not receive any fruit cups on their trays. Interview on 07/01/25 with Certified Nursing Assistant (CNA) #408 verified Residents #55 and #99 did not receive dessert or fruit cup on their lunch trays. Observation on 07/01/25 at 1:30 P.M. of Resident #28's lunch revealed a burger, chips, juice, but no fruit cup observed. Interview at the time of observation with CNA #408 verified Resident #28 had no fruit on his lunch tray. This deficiency represents non-compliance investigated under Complaint Number OH00166944. 365033 Page 2 of 3 365033 07/01/2025 Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to dry silverware and serve food in a sanitary manner. This had the potential to affect all residents except two (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Observations on 07/01/25 at 12:19 PM observed Dietary Aide (DA) #409 using a dish cloth to dry the silverware that was in a tray sitting on the end of the steam table. DA #409 proceeded to place the silverware after drying them in a silverware holder. DA #409 verified the observation and stated she didn't know they weren't supposed to dry them that way. Observations on 07/01/25 at 12:20 P.M. of the lunch tray line revealed a large pan of sliced deli meat sitting on the steam table (not in an ice bath), next to it was a large pan of lettuce, and a large pan of sliced tomatoes. [NAME] #555 tore open a loaf of white bread while wearing gloved hands, grabbed slices of bread, grabbed two slices of deli meat, folded it over onto the bread and proceeded to grab lettuce and tomato slices and place onto one slice of bread and then place the second slice of bread on top all while using the same gloved hands throughout the meal service. Interview at the time of observation with Dietary Manager (DM) #648 verified the observation and stated his expectation was for [NAME] #555 to use serving utensils. Review of the resident diet order list revealed two residents (#36 and #51) who had physician orders to receive nothing by mouth. Review of the undated facility policy, Food Preparation and Storage, revealed all food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food. 365033 Page 3 of 3