Inspection·September 27, 2022

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure a medication error rate of less than 5%. Two errors were observed in 33 opportunities resulting in a 6.06% medication error rate. This affected two (Resident's #58 and #81) of six (Resident's #4, #6, #44, #58, #61 and #81) observed for medication administration. The facility census was 82. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of [DATE] with diagnoses including hypertension, need for assistance with personal care, tremor, depression, and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 had impaired cognition and required extensive assistance of one staff with bed mobility, transfers, and personal hygiene. Review of the care plan dated [DATE] revealed Resident #81 had a self-care deficit related to cognition and tremors. Intervention included to crush medication and open capsules. Review of the [DATE] physician's order revealed orders for propranolol 60 milligrams (mg), to reduce blood pressure, every eight hours. Hold medication if heart rate is less than 60 beats per minutes (bpm) and if systolic blood pressure is less than 110. Observation on [DATE] at 8:17 A.M. revealed Licensed Practical Nurse (LPN) #214 preparing Resident #81's morning medications including the propranolol. LPN #214 walked into the room and poured the whole pills into the resident's mouth and Resident #81 swallowed the pills with a protein shake. LPN #214 was asked to review the instructions on the propranolol card which included parameters to hold the medication. LPN #214 pulled out the blood pressure machine walked into the room and took the residents blood pressure. The blood pressure was within acceptable parameter of 153 systolic over 94 diastolic and hear rate of 73 bpm. Interview on [DATE] at 8:20 P.M. with LPN #214 stated she read the parameters in the order but did not take the residents blood pressure prior to administering the medication. Review of the facility policy titled Administration and Documentation of Medications, dated [DATE], revealed the individual administering medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. The following information must be checked for each resident prior administering medication. a. Allergies to mediations b. Vital signs, if necessary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 2 of 12 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 09/27/2022 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 0759 Level of Harm - Minimal harm or potential for actual harm Nurses are responsible for ensuring vital signs, weights, or other required measurements are obtained prior to administering medications. 2. Review of the medical record for Resident #58 revealed an admission date of [DATE] with diagnoses including brain damage, respiratory failure, hypertension, and dysphagia (difficulty with swallowing). Residents Affected - Few Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #58 had impaired cognition and required total assistance of two staff with bed mobility, transfers, and personal hygiene. Review of the care plan dated [DATE] revealed Resident #58 had a self-care deficit related to coma, brain injury, and respiratory failure. Intervention included resident was a tube feed and nothing by mouth (NPO). Review of the [DATE] physician's order revealed orders for ferrous sulfate solution 300 mg/6.5 milliliter (ml), iron supplement, every morning. Give 300 mg by percutaneous endoscopic gastrostomy (PEG) a feeding tube. Observation of medication administration on [DATE] at 8:44 A.M. revealed LPN #213 preparing the resident's morning medication including the ferrous sulfate solution with an expiration date of [DATE]. LPN #213 walked into the room and stopped the feeding tube and repositioned the resident for medication administration. The surveyor stopped the medication administration and asked the LPN #213 to verify the medication and expiration date. Interview on [DATE] at 9:04 A.M. with LPN# 213 verified the ferrous sulfate had expired. LPN #213 stated she missed the expiration date when preparing the medication. Review of the facility policy titled Administration and Documentation of Medications, dated [DATE], revealed the individual administering medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. The expiration date on the medication label must be checked prior to administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 3 of 12 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 09/27/2022 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, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure tuberculin purified protein derivative (PPD) and sodium bicarbonate were stored according to manufacture guidelines. This had the potential to effect five (Resident's #8, #14, #20, #57 and #286) who were admitted in the last 30 days and three (Resident's #35, #42, and #62) who received sodium bicarbonate. The facility census was 81. Findings include: Observation on 09/21/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #213 of the second-floor medication room revealed the refrigerator had one opened multi use vial of PPD solution (used to diagnosis tuberculosis) with an expiration date of 09/26/24. There was no labeled date when the bottle was opened. There was a bottle of sodium bicarbonate (an antacid) with an expiration date of September 2020. Interview on 09/21/22 at 2:30 P.M. with LPN #213 revealed once a multi vial of tuberculin solution was opened the nurse was to document the date on the vial. Review of the manufacturer's instructions for tuberculin (PPD) solution revealed the vial should be refrigerated and protected from light. Vials in use more than 30 days should be discarded. Review of the facility policy titled Storage of Medications, dated April 2018, revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 4 of 12 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 09/27/2022 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review the facility failed to serve food at the proper portion size to meet the residents' nutritional needs. This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. The facility census was 82. Findings include: Observation 09/20/22 at 5:10 P.M. of the dinner tray line revealed diced parsley potatoes were being served with a green #12 scoop which is equivalent to two and two thirds ounces (oz). The spreadsheet for 09/20/22's dinner meal called for four oz. Whole kernel corn was being served with a green #12 scoop which is equivalent to two and two thirds oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Pureed mashed potatoes was being served with a green #12 scoop which is equivalent to two and two thirds oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Cooked vegetables for mechanical soft diets were being served with a blue #16 scoop which is equivalent to two oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Dietary Manager (DM) #207 verified the above findings and switched utensils for proper portion control sizes on 09/20/22 at 5:25 P.M. Interview on 09/21/22 at 11:36 A.M. with Registered Diet Technician (RDT) #215, Registered Dietitian (RD) #209 and DM #207 revealed RDT #215 does not do a full tray line audit. RDT #215 stated that she checked 10 residents' tray tickets to match the doctor's order. Review of the undated facility poster posted on the reach-in refrigerator located behind the steam table titled, Portion Control Chart, revealed colored scoop sizes with portion control sizes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 5 of 12 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 09/27/2022 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to employ dietary staff who could demonstrate competence in how to properly run a low temperature dish machine. This had the potential to affect all residents receiving meals from the kitchen except for two (Resident's #56 and #58) who did not receive food by mouth. The facility census was 82. Findings include: Observation and interview on 09/19/22 at 11:15 A.M. revealed Dietary Manager (DM) #207 tested the low temperature dish machine. The strips she used did not get a reading, so she checked the chemicals which revealed the sanitizer and rinse aide were emptied. Observation on 09/19/22 at 11:18 A.M. DM #207 and Dietary Aide (DA) #210 went to the storeroom to get sanitizer and returned with rinse aide and three gallons of quat sanitizer. DA #210 stated that there was no sodium hypochlorite solution sanitizer. DM #207 walked away from the dish area. Observation and interview on 09/19/22 at 11:20 A.M. revealed DA #210 was pouring quat sanitizer into the empty five-gallon sodium hypochlorite solution sanitizer bucket. DA #210 stated that DM #207 instructed him to pour quat sanitizer into the empty sodium hypochlorite solution sanitizer bucket. DA #210 stated that the dish machine does not beep or indicate when chemicals are low. DA #210 said he usually checks it at the end of the month but had not checked it today. Interview on 09/19/22 at 11:25 A.M. with DM #207 revealed she believed quat could be used in the dish machine as a ware washing sanitizer but was not sure on the concentration. Interview on 09/19/22 at 1:14 P.M. with Customer Service Representative #230 for the facility's chemical company revealed quat sanitizer was not a suitable sanitizer for a low temperature dish machine. Review of the facility's chemical company's fact sheet titled, [NAME]-Rinse Disinfectant and Sanitizer, dated 05/10/20, revealed for pre-cleaned dishes, flatware, and similar food processing equipment the pre-cleaned equipment must be immersed in a solution of one to two ounces of [NAME]-RINSE to four gallons of water (200-400 parts per million (ppm) active quat or equivalent use dilution) for one minute. Allow sanitized objects to adequately drain and then air dry BEFORE contact with food so little or no residue remains. There was no need for water rinse. Review of the facility's chemical company's fact sheet titled, Alchor; Liquid Sanitizer, dated 10/25/18, revealed the chemical's chlorine release in rinse cycles promotes free rinsing and protects food from surface contamination and bacterial growth on kitchen utensils. This product is ideal for low temperature dish machines final rinse operations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 6 of 12 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 09/27/2022 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 record review, observation, and interviews the facility did not ensure food was served at palatable temperatures This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. Residents Affected - Many Finding include: Interviews on 09/19/22 between 11:00 A.M. and 4:31 P.M. with Resident's #7 (second floor), #44 (third floor), and #79 (second floor) during the screening process of the annual survey revealed complaints about food taste and temperatures which lead to a test tray on 09/20/22. Observation on 09/20/22 at 4:31 P.M. with Corporate Food Service Manager (CFM) #208 revealed he calibrated the food thermometer to the best of his knowledge. Observation of the tray line on 09/20/22 at 5:00 P.M. revealed all hot food items on the steam table were over 165 degrees Fahrenheit (F). There was no heat retention system being used in the kitchen to keep the food warm besides the steam table, thermal domes to cover the plates, and enclosed meal delivery carts. The food truck left the kitchen at 6:04 P.M. and arrived on the unit at 6:07 P.M. When the last tray on the truck was delivered, Dietary Manager (DM) #207 went to take the temperature of the food and stated that the temperature for beef, corn, and mashed potatoes did not reach above 100 degrees F and should be hotter. Interview on 09/21/22 at 11:36 A.M. with Registered Diet Technician (RDT) #215, Registered Dietitian (RD) #209, and Dietary Manager (DM) #207 revealed RDT #215 does not do a full tray line audit. RDT #215 stated that she mostly checks the purees for temperature. The facility could not provide this surveyor with a policy of what food temperatures should be during service and did not provide requested food commitee minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 7 of 12 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 09/27/2022 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interviews, and facility policy review the facility failed to ensure residents were provided with adaptive equipment to maintain independence while eating. This affected three (Resident's #11, #39 and #81) of eight residents (Residents #4, #8, #11, #25, #39, #51, #67 and #81) who received adaptive eating equipment. The facility census was 82. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 11/07/14 and a readmission date of 12/16/14 with diagnoses including Alzheimer's disease, paranoid schizophrenia, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition and required supervision with set-up only for eating. Review of the physician's orders for September 2022 revealed a diet order for mechanical soft texture with no nutritional restrictions with thin consistency liquids. Resident #11 was also ordered a scoop plate with meals. Review of the care plan dated 10/27/21 revealed Resident #11 was at risk for altered nutritional status related to impaired cognitive function and modified consistency diet. Interventions included but were not limited to provide scoop dish with meals. 2. Review of the medical record for Resident #39 revealed an admission date of 05/04/12 with diagnoses including multiple sclerosis, bipolar disorder, paranoid schizophrenia, and anxiety. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #39 had severely impaired cognition and required extensive assistance of one staff for eating. Review of the physician's orders for May 2022 revealed a diet order for fortified diet with regular texture and thin liquid consistency. Resident #39 was also ordered a sippy cup to be use for all liquid drinks. Review of the care plan dated 10/12/21 revealed Resident #39 was at risk for altered nutritional status related to impaired cognitive function, self-feeding difficulty, and low body weight. Interventions included but were not limited to have a sippy cup to be use for all liquid drinks. 3. Review of the medical record for Resident #81 revealed an admission date of 11/07/14 and a readmission date of 04/24/19 with diagnoses including major depressive disorder, specified forms of tremors, and unspecified mood disorder. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #81 was not assessed for cognition and required supervision with set up only for eating. Review of the physician's orders for September 2022 revealed a diet order for fortified diet with regular texture and thin liquid consistency. Resident #81 was also ordered a blue scoop dish and weighted utensils with meals. Review of the care plan dated 01/14/20 revealed Resident #81 was at risk for altered nutritional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 8 of 12 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 09/27/2022 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few status related to impaired cognitive function, self-feeding difficulty, and therapeutic diet. Interventions included but were not limited to provide scoop dish and weighted utensils with meals. Observation and interview on 09/20/22 5:00 P.M. to 6:04 P.M. revealed the following: Resident #11 did not receive a scoop dish/plate. [NAME] #122 stated that there were no more scoop dishes/plates in the kitchen. Resident #39 did not receive a sippy cup. Dietary Manager #207 stated there were no sippy cups and nursing doesn't return them to the kitchen. Resident #81 did not receive a blue scoop dish and weighted silverware. Dietary Aide #211 replaced the silverware with the weighted utensils. [NAME] #122 stated that there were no more scoop dishes in the kitchen. Interview on 09/21/22 at 11:36 A.M. with Registered Diet Technician (RDT) #215, Registered Dietitian (RD) #209 and Dietary Manager (DM) #207 revealed RDT #215 does not do a full tray line audit. RDT #215 stated she checks ten residents tray tickets to ensure they match the doctor's order. Review of the facility policy titled, Adaptive Equipment, dated 09/08/21, revealed adaptive devices shall be provided to residents who need them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 9 of 12 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 09/27/2022 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and facility policy review the facility failed to ensure proper ware washing and a clean and sanitary kitchen. This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. Findings include: 1. A tour of the kitchen on 09/19/22 from 11:00 A.M. to 11:25 A.M. revealed the following: • The walk-in freezer had garlic bread, veal patties, and chicken patties not wrapped properly, labeled, or dated. • Bins that had barley, sugar, and rice were not labeled and dated, and the sugar and rice had scoops sitting directly on the food. • The walk-in refrigerator brats were not wrapped properly, labeled, or dated. Interview on 09/19/22 at 11:07 A.M. [NAME] #102 verified the above observations. Review of the facility policy titled, Labeling and Dating, dated 09/08/21, revealed leftovers and opened items shall be clearly labeled with the date the food item was to be discarded. 2. Observation and interview on 09/19/22 at 11:15 A.M. revealed Dietary Manager (DM) #207 tested the low temperature dish machine. The strips she used did not get a reading, so she checked the chemicals which revealed the sanitizer and rinse aide were emptied. Observation on 09/19/22 at 11:18 A.M. DM #207 and Dietary Aide (DA) #210 went to the storeroom to get sanitizer and returned with rinse aide and three gallons of quat sanitizer. DA #210 stated that there was no sodium hypochlorite solution sanitizer. DM #207 walked away from the dish area. Observation and interview on 09/19/22 at 11:20 A.M. revealed DA #210 was pouring quat sanitizer into the empty five-gallon sodium hypochlorite solution sanitizer bucket. DA #210 stated that DM #207 instructed him to pour quat sanitizer into the empty sodium hypochlorite solution sanitizer bucket. DA #210 stated that the dish machine does not beep or indicate when chemicals are low. DA #210 said he usually checks it at the end of the month but had not checked it today. Interview on 09/19/22 at 11:25 A.M. with DM #207 revealed she believed quat could be used in the dish machine as a ware washing sanitizer but was not sure on the concentration. Interview on 09/19/22 at 1:14 P.M. with Customer Service Representative #230 for the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 10 of 12 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 09/27/2022 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 chemical company revealed quat sanitizer was not a suitable sanitizer for a low temperature dish machine. Level of Harm - Minimal harm or potential for actual harm Review of the facility's chemical company's fact sheet titled, [NAME]-Rinse Disinfectant and Sanitizer, dated 05/10/20, revealed for pre-cleaned dishes, flatware, and similar food processing equipment the pre-cleaned equipment must be immersed in a solution of one to two ounces of [NAME]-RINSE to four gallons of water (200-400 parts per million (ppm) active quat or equivalent use dilution) for one minute. Allow sanitized objects to adequately drain and then air dry BEFORE contact with food so little or no residue remains. There was no need for water rinse. Residents Affected - Many Review of the facility's chemical company's fact sheet titled, Alchor; Liquid Sanitizer, dated 10/25/18, revealed the chemical's chlorine release in rinse cycles promotes free rinsing and protects food from surface contamination and bacterial growth on kitchen utensils. This product is ideal for low temperature dish machines final rinse operations. Review of the facility policy titled, General cleaning of equipment, dated 10/01/21, revealed basic cleaning equipment will be maintained in a clean and sanitary condition after every use to ensure food safety. 3. Observation on 09/20/22 at 5:20 P.M. revealed [NAME] #122 was serving breadsticks with his gloved hand then reached for serving utensils to dish food. Dietary Manager (DM) #207 gave [NAME] #122 a pair of tongs. [NAME] #122 did wash his hands and change gloves. [NAME] #122 continued to pick up the breadsticks with his gloved hand. Interview on 09/21/22 at 11:36 A.M. with Registered Diet Technician (RDT) #215, Registered Dietitian (RD) #209 and Dietary Manager (DM) #207 revealed RD #209 does kitchen sanitation audits monthly in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 11 of 12 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 09/27/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and facility policy review the facility failed to ensure proper infection control during glucose monitoring. This affected one (Resident #6) of five (Resident's #6, #13, #22, #31 and #45) who received glucose monitoring on the second-floor east unit. The facility census was 82. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 09/23/221 with diagnoses including type II diabetes, paranoid schizophrenia, and dementia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had impaired cognition and received insulin. Review of the care plan dated 04/14/22 revealed Resident #6 had a self-care deficit related to coma, brain injury, and respiratory failure. Intervention included resident had a tube feed and was to receive nothing by mouth (NPO). Review of the September 2022 physician's order revealed order for NovoLog 100 units per millimeter (ml), an insulin, to be injected per sliding scale for a blood glucose reading: 0 units for reading less than 200 2 units for reading 201 to 250 4 units for reading 251to 300 6 units for reading 301 to 350 8 units for reading 351 to 400 Observation on 09/21/22 at 7:55 A.M. of glucose monitoring with Licensed Practical Nurse (LPN) #213 with Resident #6 revealed LPN #213 gathering supplies and washing her hands and donning gloves. LPN #213 wiped the left index finger with alcohol then pricked the finger and drew a drop and applied it to the glucose strip. The glucometer read an error. LPN #213 did not remover her gloves or wash her hands. She went back to the cart opened it up and retrieved a new glucose strip. With the same gloves, LPN #213 went back into the Resident #6's room and pricked the finger and redrew a sample of blood. LPN #213 disposed the lancets and washed her hands and left the room. Interview with LPN #213 at this time stated she did not realize she went back to the cart without washing hands or changing gloves. Review of the facility policy titled Blood Sampling, revised September 2014, revealed after obtaining the blood sample, discard the lancet in the sharps container, remove gloves, and wash hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 12 of 12