Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CEDARWOOD PLAZA
CLEVELAND HEIGHTS, OH · 115 certified beds · Last Life Safety survey September 28, 2023
CMS Certification Number 365033 · first certified January 1967
Ownership
Operated by LEGACY HEALTH SERVICES · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OH
23 citations — more than 73% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2025 to May 2026), and past the point by which nine in ten OH facilities have been surveyed. This facility’s last Life Safety survey was September 2023. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 31, 2019 | 4 |
| March 12, 2020 | 10 |
| September 28, 2023 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2023-09-28 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-09-28 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2023-09-28 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2020-03-12 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-09-28 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2023-09-28 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2020-03-12 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2019-01-31 |
What the citations cover
- Smoke Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 3
- Construction Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 28, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 18, 2023) |
March 12, 2020 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has plan of correction (April 1, 2020) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | Deficient, Provider has date of correction (April 1, 2020) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 1, 2020) |
January 31, 2019 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 28, 2019) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (February 28, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 28, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 28, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.