Cycle 1
Health 2023-09-28 · Fire 2023-09-28
17 health deficiencies
Top issue: Nutrition and Dietary (9 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cleveland Heights, OH
Cedarwood Plaza
2-star overall rating with 1-star inspections with $8,171 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
12504 Cedar Road, Cleveland Heights, OH
(216) 371-3600
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
115
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Health Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.99
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,998
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.87
Baseline 73.79% · Performance 57.28% · Measure score 2.87 · Achievement 1.57 · Improvement 2.87
Adjusted total nurse staffing
0
Baseline 3.03 hours · Performance 2.81 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.76% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 6.3% |
| Discharge to community | 47.02% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 33.33% · Lower 95% interval 31.59% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 203 |
| Staff flu vaccination coverage | 0.94% |
42%
41.1 pts worse
|
Numerator 3 · Denominator 319 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
92.4%
2.2 pts better
|
93.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 95.6% · Q3 94.8% · Q4 93.5% · 4Q avg 94.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 59.9% |
26.1%
33.8 pts worse
|
11.4%
48.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.7% · Q2 61.2% · Q3 57.0% · Q4 59.3% · 4Q avg 59.9% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
6.2%
1.7 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.4% · Q3 2.3% · Q4 8.3% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
25.4%
20 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.9% · Q3 6.8% · Q4 5.9% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.0% |
11.5%
9.5 pts better
|
16.7%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 3.1% · Q4 3.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.3% |
7.7%
4.4 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 4.4% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
6.2%
2.8 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 1.2% · Q3 1.2% · Q4 4.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.2%
0.1 pts worse
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.5%
About the same
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.4% |
21.7%
10.7 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 35.3% · Q3 31.4% · Q4 34.8% · 4Q avg 32.4% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
3.7%
2.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.3% · Q3 1.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.4% |
78.1%
9.7 pts worse
|
81.7%
13.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 71.0% · Q3 67.7% · Q4 57.9% · 4Q avg 68.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.5% |
75.6%
1.9 pts better
|
79.7%
2.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-03-12 · Fire 2020-03-12
10 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-01-31 · Fire 2019-01-31
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-28
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-18
E · Potential for more than minimal harm
2020-03-12
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2020-04-01
E · Potential for more than minimal harm
2020-03-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-01
C · Minimal harm
2020-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-04-01
E · Potential for more than minimal harm
2019-01-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-02-28
E · Potential for more than minimal harm
2019-01-31
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-02-28
E · Potential for more than minimal harm
2019-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-28
E · Potential for more than minimal harm
2019-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-02-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-14
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-10-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-10-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-10-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-10-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-10-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-17
F · Potential for more than minimal harm
2025-08-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-08-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-01
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-07-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-02-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-06
E · Potential for more than minimal harm
2025-02-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-09
J · Immediate jeopardy
2024-05-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-06
F · Potential for more than minimal harm
2024-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-16
F · Potential for more than minimal harm
2023-09-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-28
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-10-18
F · Potential for more than minimal harm
2020-03-12
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2020-04-01
D · Potential for more than minimal harm
2020-03-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-04-01
D · Potential for more than minimal harm
2020-03-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-04-01
D · Potential for more than minimal harm
2020-03-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-04-01
D · Potential for more than minimal harm
2019-01-31
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-02-28
D · Potential for more than minimal harm
2019-01-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-02-28
Penalties and ownership
What sits behind the stars
$8,171
2024-05-15
Fine
Fine · fine $8,171
Fine
Ownership
Oh 10 Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Cc Oh10 Opco LLC
5% Or Greater Indirect Ownership Interest · Organization
Chavos221 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Chavos221 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Lionsview Opco Nr LLC
5% Or Greater Indirect Ownership Interest · Organization
Lionsview Sc LLC
5% Or Greater Indirect Ownership Interest · Organization
Living26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Living26 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Sapphire143 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sapphire143 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Sharvit, Eliav
Corporate Officer · Individual
Stump, Barry
Corporate Officer · Individual
Stump, Barry
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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4-star overall rating with 4-star inspections with $25,847 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
University Manor Health & Reha
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1-star overall rating with 1-star inspections with $32,394 in total fines with 15 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
The Gardens Of Fairfax Health Care Center
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1-star overall rating with 1-star inspections with $200,208 in total fines with 21 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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