Inspection·September 12, 2019

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based resident and staff interview the facility failed to obtain written authorization from the resident or responsible party prior to managing a residents personal funds. This affected one (Residents #12) of eight resident accounts reviewed This had the potential to affect all residents that have accounts. The facility census was 112. Residents Affected - Few Findings Include: Residents #12 was admitted to the facility on [DATE] with diagnoses that included, schizophrenia, type two diabetes and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 cognitively intact. Review demographic information Resident #12 revealed he was his own responsible party. Review of the business office file for Resident #12 noted monthly deposits of 300$ entitled private sector ck deposited into an account managed by the facility. Further review of the business office file for Resident #12 revealed no evidence Resident #12 signed for authorization for the facility to manage his funds. Interview with Business Manager (BM) #300 at 11:30 A.M. verified the facility did not have signed consent to manage Resident #12's funds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 2 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #164) of one residents reviewed for funds conveyance. The facility census was 112. Residents Affected - Few Findings Include: Resident #164 was admitted to the facility on [DATE]. Resident #124 expired at the facility on [DATE]. Review of the business records for Resident #164 revealed two separate checks for $21.75 and $1,000 dollars were dispersed to the funeral home handling Resident #164's arrangements on [DATE]. Business Manager #300 verified that Resident #164's funds were conveyed outside of required timeframes (30 days) in an interview on [DATE] at 1:35 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 3 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure a level two pre admission screen and resident review (PASRR) assessment was completed timely as required. This affected one (Resident #76) of two residents reviewed for PASRR status. The facility census was 112 Residents Affected - Few Findings Include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, hypertension and nicotine dependence Review of the pre admission screen determination from the local area agency on aging dated 11/95/18 revealed Resident #12 had a level two mental illness and was approved for a seven day stay at the nursing home and that continued stay at the facility required a level two evaluation from the contracted state agency (The Ohio Department of Mental Health) Review of both the electronic and hard charts revealed no other PASRR documentation in Resident #12's record indicating continued approval for stay at the nursing home or that any follow up level two assessment was conducted. Social Worker #999 verified no valid PASRR was in place for Resident #12's continued stay at the facility in an interview on 09/12/19 at 9:3 A.M. Phone interview with PASRR worker #998 at the Ohio Department of Mental Health further verified no valid PASRR was in place for Resident #12's continued stay at the nursing facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 4 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to assess resident blood glucose levels in a timely manner. This affected one (Resident #91) of 27 residents who receive blood glucose testing (Resident #73, #102, #44, #311, #17, #81, #42, #78, #4, #92, #105, #95, #22, #106, #12, #10, #2, #60, #94, #90, #16, #24, #13, #101, #48, #32, and #91). The total census was 112. Residents Affected - Few Findings include: Observation of a blood glucose assessment procedure by Licensed Practical Nurse (LPN) #301 for Resident #91 on 09/10/19 at 9:14 A.M. revealed Resident #91 had already received their breakfast tray and consumed roughly two-thirds of the food on it. Measurement of Resident #91's blood glucose level revealed it to be within normal limits (a value of 92). Interview with LPN #301 immediately following the observation confirmed the glucose check was done late, and was scheduled to be done daily at 8:00 A.M. Record review of Resident #91 revealed an order for blood sugar monitoring to be done once per day at 8:00 A.M. No evidence could be found specifying it was acceptable to wait until after breakfast to assess it. Review of the facility's blood glucose testing policy (undated) revealed clarification that ongoing glucose monitoring was necessary to detect extremes in blood glucose levels and determine effectiveness of the treatment plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 5 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the physician's diet order was followed for Resident #30. This affected one resident (Resident #30) out of four (Residents #10, #30, #52 and #77) reviewed for nutrition. The facility census was 112. Residents Affected - Few Findings include: Review of resident's medical record revealed Resident #30 was admitted on [DATE] with diagnoses including but not limited to paranoid schizophrenia, conversion disorder with seizures or convulsions, alkalosis, and chronic pulmonary disease. Resident # 30's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with one person for most Activities of Daily Living (ADLs) except eating is supervision with set up only. Further review of Resident #30's medical record revealed that nutritional assessment dated [DATE] revealed he was below his Ideal Body Weight (IBW), had a corn intolerance and resident preferred double entrees with a peanut butter and jelly sandwich in addition to lunch and dinner trays. Resident #30's Body Mass Index (BMI) was 14.1, which indicates underweight. Observation of lunch meal tray pass on 09/11/19 at 1:20 P.M. with Consulting Dietary Manager #261 revealed that Resident #30's tray was missing the soup, a sandwich and only received single portions of the entrée. His tray ticket stated that he was supposed to get double portions and a bologna sandwich. Interview on 9/11/19 at 2:27 P.M. with Registered Dietitian revealed that Resident #30 was admitted underweight and would not take supplements because it bothered him, so he agreed to get double portions and has gained three pounds. She stated that currently his BMI is 14.7. Review of the policy entitled, Philosophy of Diet and Nutrition Therapy for Skilled Nursing Communities revealed that each resident is provided with a nutritional, palatable, well-balanced diet that meets his daily nutritional and special dietary needs, taking into consideration the preferences of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 6 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview the facility failed to ensure medications were stored in a secured manner. This affected the 44 residents (Residents #4, #14, #15 #17, #20, #21, #25, #26 #28, #29, #30, #37, #38, #39 #42, #44, #47, #49, #52, #55, #60, #62, #64, #69 #70, #71, #72, #73, #75, #77, #78, #81, #83, #86, #88,#91, #92, #95, #97, #102, #104, #105, #311 and #312.) who resided on the first floor and the two south unit. This affected and two of three medication carts observed. The facility census was 112. Findings Include: 1. Observation of the first floor nurse's medication cart on 09/12/19 between 10:44 A.M. and 11:00 A.M. with Registered Nurse (RN) #944 revealed three unidentified loose pills at the bottom of multiple drawers through out the medication cart. RN # 944 verified the findings in an interview on 09/12/19 at 11:00 A.M. 2. Observation of the two unit south nurse's medication cart on 09/12/19 between 11:00 A.M. and 11:08 A.M. with Licensed Practical Nurse (LPN) #945 revealed twelve unidentified loose pills at the bottom of multiple drawers through out the medication cart. LPN #945 verified the loose pills in an interview on 09/12/19 at 11:08 A.M. Review of the policy entitled Storage of Medications dated 04/01/07 revealed Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems The facility identified 44 residents (Residents #4, #14, #15 #17, #20, #21, #25, #26 #28, #29, #30, #37, #38, #39 #42, #44, #47, #49, #52, #55, #60, #62, #64, #69 #70, #71, #72, #73, #75, #77, #78, #81, #83, #86, #88,#91, #92, #95, #97, #102, #104, #105, #311 and #312) as residing on the 1st floor and two unit south and having medications in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 7 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 109 out of 112 residents who ate meals in the facility's kitchen. Three Residents (#37, #52 and #70) received nothing by mouth. The facility census was 112. Residents Affected - Some Finding Include: Interviews by the survey team were made on 09/09/19 between the hours of 8:45 A.M. and 3:00 P.M., Residents #14, #42, #49, #101 and #106 revealed that the food was not served at a palatable temperature. Interviews during the annual survey's resident council on 09/11/19 at 2:30 P.M., Residents #16, #42, #88, #103 and #107 revealed that the food was not served at a palatable temperature many of the meals. On 09/11/19 at 12:05 P.M. a test tray was requested due to multiple complaints about the temperature of the food. The food truck left the kitchen at 1:02 P.M. and arrived on the unit at 1:04 P.M. Food temperatures on the steam table at 12:38 P.M. revealed that all cold food 40 degrees Fahrenheit (F) according to Consulting Dietary Manager (DM) #261. The test tray was conducted by DM #261 on 09/11/19 at 12:49 P.M. He used a digital thermometer. The egg salad sandwich measured 71 degrees F, macaroni salad 61.5 degrees F, and fruit salad measured 74 degrees F. The test tray did not have a vegetable item on it and could not measure. Interview with DM #261 verified that the temperatures should be colder. Interview on 09/11/19 at 10:13 A.M. with Registered Dietitian revealed that tray accuracy and test tray audits are done on a as needed basis. Review of undated dietary policy entitled, Food Temperatures revealed that cold foods should be cooled down to 41 degrees F and food is to be held at 41 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 8 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, taste test and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected eight out of eight residents (#7, #19, #20, #34, #44, 60, #83, and #85) who were prescribed a pureed diet of 109 residents who consumed meals from the facility's kitchen. Residents #37, #52 and #70 received nothing by mouth. The facility census was 112. Findings include: Observation on 09/11/19 at 12:05 P.M. of the lunch meal revealed that the pureed egg salad and pureed macaroni salad had pieces of pimentos on the surface and did not appear smooth. The pureed egg salad and macaroni salad were tasted. The mixture was not smooth and not of proper consistency. Consulting Dietary Manager (DM) #261 verified the consistency of the pureed egg salad and pureed macaroni salad. The Purred egg salad and macaroni salad was at proper consistency at 12:38 P.M. Review of resident diet list revealed residents (#7, #19, #20, #34, #44, 60, #83, and #85) who were prescribed a pureed diet. This was verified by the Registered Dietitian on 09/11/19 at 2:27 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 9 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, record review and interview, the facility failed to ensure meals were delivered in a timely manner in accordance to the posted meal times. This affected 109 out of 112 that ate meals in the facility. Residents #37, #52 and #70 received nothing by mouth. The facility census was 112. Finding include: Observation on 09/09/19 from 12:00 to 1:40 P.M. of the lunch meal revealed lunch was delivered to the first floor at 12:47 P.M., second floor was delivered at 1:13 P.M. and third floor was delivered at 1:36 P.M. Interview on 09/09/19 at 12:47 P.M. with Regional Nurse #117 verified the meal times at 12:45 P.M. by giving this surveyor a copy of the meal times. Meal times were as followed: first floor trays to be delivered at 12:00 P.M., second floor at 12:15 P.M. and third floor at 12:45 P.M. and the second truck to third floor at 1:00 P.M. Administrator verified that trays were delivered on first floor at 12:47 P.M., State Tested Nurse Aide (STNA) #30 and STNA #89 verified that second floor was delivered at 1:13 P.M. Trays for third floor were delivered at 1:36 P.M., interview with STNA #95on 09/09/19 at 01:56 PM revealed that today is latest that food trays arrived. Normal arrival time for trays on the third floor is usually between 12:15-12:30 PM. Interview on 09/09/19 at 12:48 P.M. with Assistant Director of Nursing #96 revealed that first the first floor gets their trays first then the second floor and finally the third floor. Nursing would have to call and find out what the delay is in the kitchen. Interview on 09/10/19 at 2:00 P.M. with Administrator #97 revealed that the former food service management company left on 08/31/19 and the department has been a mess. They took a lot of information regarding the dietary department. Review of posted meal times revealed that lunch trays should have arrived on the first floor at 12:00 noon, second floor at 12:15 P.M. and third floor at 12:45 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 10 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure the kitchen was maintained in a clean and sanitary manner. This affected 109 out 112 residents who received meals from the dietary department. Resident #37, #52, and #72 were Nothing by Mouth (NPO) and did not receive meals prepared by dietary staff. The facility census was 112. Findings: A tour of the kitchen was conducted on 09/09/19 with the Maintenance Director (MD) #100 from 8:09 A.M. through 8:30 A.M. because the Dietary Manager (MD) was working on breakfast trays. Observation of the kitchen revealed dietary worker #101 was not wearing a hair net; the floors under the dish machine, kitchen oven steamer, and convection oven was covered with heavy dirt and grease build up. The wall by the dish machine contained a heavy black substance. Inspection of the metal transportation meal carts contained dry food particles on the racks and paper on the bottom of the cart Observation of the storage ben holding cooking flour, contain a scoop inside the storage ben. The walk-in cooler contained four large pieces of meet properly wrapped were not dated, as well as one bag of vegetables. The wall out side the open area where the dirty trays are unloaded for washing contain food splatter over a large area. Interview with MD #100 on 09/09/19 at 8:30 A.M. verified the observations above. A follow up visit was conducted on 09/10/19 at 10:20 A.M. revealed food splatter on the ceiling light covers, kitchen oven steamer, and convection oven was covered with heavy dirt and grease build up. Kitchen oven steamer, and convection oven was covered with heavy dirt and grease build up. The wood fixture by the warmer pan contained peeling paint and deteriorating wood, and the mixer contained dry food particles underneath the attachment socket for the mixing blade. Interview with the Consulting Dietary Manager (CDM) #261 on 09/10/19 at 10:30 A.M. verified the findings. Review of the Cleaning Standard and the Safe Appearance and Hygiene Policies identified expectations and procedures for kitchen appearance and cleaning /sanitation standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 11 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure proper infection control when administering medications and blood glucose tests. This affected one (Resident #81) of two (Resident #81 and #311) residents on IV (intravenous) medications, and one (Resident #91) of 27 residents who receive blood glucose testing (Resident #73, #102, #44, #311, #17, #81, #42, #78, #4, #92, #105, #95, #22, #106, #12, #10, #2, #60, #94, #90, #16, #24, #13, #101, #48, #32, and #91). The total census was 112. Residents Affected - Few Findings include: 1. Observation of an IV medication administration for Resident #81 by Registered Nurse (RN) #300 on 09/10/19 at 8:33 A.M. revealed she did not wear protective gloves at any point during the procedure, including using an alcohol swab to cleanse the resident's IV access, administering a normal saline flush, and connecting the tubing for the IV medication to the resident. The surveyor confirmed the above observation in interview with RN #300 on 09/10/19 at 8:42 A.M. RN #300 said she did not have to wear gloves at that time because she did not touch any part of the IV that directly connected with the resident's IV access. Review of the facility's Administering Medications via Secondary Tubing policy dated 12/2012 revealed staff was to wash hands and don non-sterile gloves when administering IV medications. 2. Observation of a blood glucose monitoring (accucheck) procedure for Resident #91 by Licensed Practical Nurse (LPN) #301 on 09/10/19 at 9:14 A.M. revealed LPN #301 wiped the glucometer with an alcohol swab before using it to perform the blood test. She did not do any other cleaning or sanitizing of the glucometer before or after the procedure. Interview with LPN #301 immediately following the above observation revealed she was aware she should have used bleach wipes to clean the glucometer before and after the procedure. She did not because there were no bleach wipes available on her medication cart. Review of the facility's blood glucose testing policy (undated) revealed clarification that ongoing glucose monitoring was necessary to detect extremes in blood glucose levels and determine effectiveness of the treatment plan. After the glucose test, staff was to don gloves and disinfect the glucometer according to manufacturer guidelines prior to storing. Review of the Assure Platinum blood glucose monitor instruction manual furnished by the facility revealed the monitor could be disinfected with commercially available disinfectant detergent or germicide wipes, or by using a diluted bleach solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 12 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on record review and staff interview the facility failed to maintain a clean and sanitary environment. This affected all residents. This affected all 75 resident occupied rooms. The facility census was 112. Residents Affected - Many Findings Include: 1. Observation of Resident #95's room on 09/09/19 at 9:15 A.M. revealed dried fecal matter on the floor and toilet seat. The facilities Administrator verified the dried fecal matter at the time of discovery. 2. Observation of Resident #4 on 09/09/19 at 11:00 A.M. revealed Resident #9 was laying perpendicular in her bed and significant areas of dried blood were noted on the sheet of the bed. Licensed Practical Nurse #100 verified the blood stains at the time of discovery. 3. An environmental tour was conducted on 09/10/19 between 9:22 A.M. and 10:09 A.M. with Maintenance Director #901. The following was observed and verified at the time of discovery. Resident #41 was observed laying in bed on a pillow case that was stained brown. The rooms belonging to Residents #2, #3, #4 #5,#6, #7, #8, #9, #10, #11, #12 #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #29, #30 #31, #32 #33, #34, #35, #36, #38, #39, #40, #41, #43, #47, #48, #49, #50, #51, #52 #54, #55, #56, #58, #59, #61, #62, #63, #64, #66, #67, #68, #69 #71, #72, #73, #74, #75, #77, #78, #79 #80, #81, #82, #83, #85, #86, #87, #88, #89, #90, #91, #93, #95, #97 #98, #99, #100, #101, #102, #103, #104, #105, #106, #109, #110, #115, #120 #161, #162, #163, #311 #361 contained air conditioning units that were unkempt, unclean and in disrepair to various degrees. The room belonging to Resident #28 contained a significantly rusted trapeze (transfer device) handle. The rooms belonging to Resident #8, #17 #28, #47, #68, #73 #75 #87, #88, #110 contained missing closet doors. The room belonging to Residents #2, #14, #161 and #162 contained numerous missing vertical blinds The room belonging to Resident #71 contained a fan above the bed that was coated in dust and other substances on the blade and covering of the fan. The room belonging to Residents #25 and #104 door to the bathroom was dislodged and completely off its tracks. The rooms belonging to Residents #6, #15, #38, #41 #49, #52, #62 #64 #66, #71, #79, #86 and #102 contained various levels of dirt and discoloration in the bathroom floors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 13 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0921 The rooms belonging to Residents #32, #36, #89 and #169 contained stained and dirty privacy curtains. Level of Harm - Minimal harm or potential for actual harm The room belonging to Residents #76 and #107 contained an outlet that was dislodged from the wall. The room belonging to Residents #99 and #361 contained a cracked bathroom mirror. Residents Affected - Many The room belonging to Resident #30 contained blinds that were black in color from dirt and dust build up. The rooms belong to Residents #3, #13, #16, #24, #33, #39, #56, #58 #59, #67, #80 and #306 contained water stained ceiling tiles in various places throughout the room. The room belonging to Resident #56 contained a bed side dresser that had significant food stains and discoloration. The rooms belonging to Residents #7, #12, #21, #22, #27, #35, #44, #51, #52, #56, #58, #64, #69, #83 #98, #100 and #312 contained significant scrapping and/or scuffing on the walls. The tube feed and intravenous medication poles belonging to Resident #37, #52, #60 and #70 were noted to be stained with dried tube feed, dirty and other various substances. The heater covers in the room belonging to Resident #53 was significantly bent. Part of the baseboard in the room belonging to Resident #32 and #163 was off the wall exposing crumbling dry wall. A significant portion (approximately 20%) of the bathroom tile in Resident #9 and #101's room was missing. The bed belonging to Resident #54 contained numerous rips and tears exposing its padding. Resident #72 was observed sleeping in a blanket with brown stains. Review of the facilities policy entitled housekeeping revealed the facility will be clean on a regular basis according to a specified cleaning schedule and according to Federal/state guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 14 of 15 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 365353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Candlewood Healthcare and Rehabilitation 1835 Belmore Ave East Cleveland, OH 44112 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure its kitchen were free from pests (flies) by having an affective pest control system. This had the potential to affect 109 of 112 residents in the facility. The facility census was 112. Residents Affected - Some Findings include: Observations during the initial tour of the kitchen on 09/09/19 from 8:09 A.M. through 8:30 A.M. with Maintenance Director (MD) #100 revealed there were 12-15 flies near the open section of the dish machine where dirty trays were sent through for washing and trash cans were kept. During this tour of the kitchen, the Consulting Dietary Manager (CDM) #261 could not be present because he was helping with the breakfast trays. Interview with MD #100 on 09/09/19 at 8:30 A.M. verified the observations above. A follow up visit was made on 09/10/19 at 10:20 A.M. with the CDM #261 at 10:20 A.M. revealed multiple flying pest (flies) near the open section of the dish machine where dirty trays were sent through for washing and trash cans are kept. Interview with the CDM #261 on 09/10/19 at 10:20 A.M. verified the findings and would have their pest control company come out the same day. Review of pest control contract dated 03/23/18 revealed that services will be provided. The company did come out to the facility on [DATE], This was confirmed by the CDM #261 on 09/10/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 15 of 15