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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 365033 Printed: 05/15/2026 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 365033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 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)