Inspection·October 16, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Review of comprehensive care plan , completion date 08/08/23, revealed Resident #7 was at risk for potential verbal aggression when frustrated. Goal for Resident #7 was to verbalize understanding of need to control verbally abusive behavior through the review date. Interventions included staff to remain calm and not raise voice, encourage Resident #7 to vent feelings, staff not to take resident's behavior personally, encourage resident to participate in individual or group activities, and notify physician related to medication. Residents Affected - Few Review of a nursing note dated 10/10/23 written by Licensed Practical Nurse ( LPN) #424 revealed loud voices with cursing and yelling in the room of Resident #7 and Resident #8. LPN #424 observed Resident #7 in Resident #8's bed. Resident #8 was on top of Resident #7 hitting him with his fist. Resident #7 was choking Resident #8 and hitting his face. Resident #8 was bleeding from the mouth and under right eye and his neck was very red. SR #8 had a laceration under his right eye. The medical director and family were informed. Review of the facility document titled Skin Grid Non-Pressure V5, dated 10/09/23, written by LPN #424 revealed Resident #8 had red marks on his neck and a skin tear on face measuring 0.5 centimeters (cm) in length by 0.5 cm in width and 0.1 cm depth. The wound had sanguineous bloody drainage. Review of a nursing note dated 10/10/23 written by LPN #325 revealed Resident #8 returned from the hospital that morning with no new orders and vital signs within normal limits. Resident #8 was moved to another room. A message was left for the guardian to call back regarding the update on the room change. Review of Resident #8's hospital emergency visit summary on 10/09/23 revealed an admission diagnosis of assault. Imaging tests were ordered of the cervical spine, head and maxillofacial bones and a chest x ray. All results were negative and Resident #8 was discharged back to the facility on [DATE] Review of the facility SRI investigation, dated 10/10/23 , revealed at 10:30 P.M. the administrator received a call from the second-floor charge nurse to report Resident #7 and Resident #8 were in an altercation. The preliminary investigation revealed Resident #7 stated the roommate (Resident #8) was masturbating in bed, and Resident #7 wanted him to stop. Resident #8 reported Resident #7 came over to his side of the room and began making derogatory remarks about his family. Both residents were immediately separated. Resident #8 had a laceration under his eye and was bleeding from the mouth. Police were called. Resident #7 was placed on every 15-minute checks and Resident #8 was transported to the emergency room. Both of the resident's representatives and physicians were notified. The facility unsubstantiated the allegation of abuse indicating the resident's indicated they had a disagreement, hit each other but denied feeling abused. Review of the witness statement dated 10/09/23 authored by State Tested Nursing Assistant (STNA) #379 revealed she heard the nurse responding to a resident altercation and followed the nurse down the hall. Resident #8 was on top of Resident #7 pounding him in the face with his fist. The staff worked together to deescalate the situation. Review of the witness statement dated 10/09/23 authored by Licensed Practical Nurse (LPN) #424 revealed she heard cursing and yelling and went to the room of Resident #7 and Resident #8 to find Resident #8 on top of Resident #7 hitting him in the face and Resident #7 was choking Resident #8. Review of the witness statement dated 10/09/23 authored by STNA #302 revealed she heard the nurse scream for help, went to the room of Resident #8 and Resident #7 and saw Resident #8 on top of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 2 of 4 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 10/16/2023 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 0600 Resident #7 punching him in the face. STNA #302 and the other staff broke up the fight. Level of Harm - Minimal harm or potential for actual harm Review of the witness statement dated 10/09/23 authored by STNA #311 revealed she witnessed Resident #7 and #8 fighting with each other. Residents Affected - Few Interview on 10/12/23 at 9:46 A.M. with the Executive Director( ED) revealed as of 09/01/23 Resident #7 and SR #8 were roommates. The ED verified the altercation with Resident #7 and #8. The ED verified SR #8 had a laceration under the eye and blood from the mouth and needed to go to the hospital emergency room. Resident #7 did not have any injuries and refused to go the hospital. Interview on 10/12/23 at 2:45 P.M. with Resident #8 revealed he felt Resident #7 did not like him because he masturbated. Resident #8 stated Resident #7 scratched him and he was not missing any teeth. Resident #8 stated he did not feel safe because his roommate would start fights with him. Resident #8 also stated he did not feel scared now that he was away from Resident #7. Observation during this interview revealed Resident #8 had a pink laceration under the right eye and a pink laceration on the neck. Interview on 10/10/23 at 3:00 P.M. with Resident #7 revealed Resident #8 did not have his curtain closed when he was masturbating and that bothered him. Resident #7 stated he was upset because nobody should have to see that. Interview on 10/12/23 with STNA #379 who witnessed the event stated Resident #7 would get upset easily. STNA #379 said Resident #8 had blood under his eye and blood in his mouth from the fight with Resident #7. Interview on 10/12/23 at 1:29 P.M. with LPN #332 stated Resident #8 had a cut under eye and welts around his neck from being choked during the fight with Resident #8. Resident #8 was nervous because of what happened but presently not scared. The ambulance took Resident #8 to the hospital emergency room for evaluation of his injuries. Interview on 10/12/23 at 1:32 P.M. with STNA #311 revealed she was in the linen room on the night of 10/09/23 and heard screaming. Resident #8 was on top of Resident #7 fighting. STNA #311 verified Resident #8 had a cut under his eye and a scratch on the resident's neck. Interview on 10/12/23 at 1:42 P.M. with STNA #329 revealed she was called to help with the altercation. Both residents were separated and kept safe that night. Interview on 10/12/23 at 5:30 P.M. with LPN #424 revealed she was sitting behind the nurse station and heard yelling down the hall. When LPN #424 entered the room Resident #8 was on top of Resident #7 and Resident #8 had a bloody mouth and a cut eye. LPN #424 called for help immediately and the staff separated the two residents to keep them safe. LPN #424 called 911 and stayed with Resident #8 until the ambulance arrived and transported the resident to the hospital. Interview on 10/12/23 at 12:49 P.M. with Social Worker Designee (SWD) #301 revealed both Resident #7 and #8 had no history of not getting along, but Resident#7 was uncomfortable with Resident #8 masturbating in their room. SWD #310 met with both residents on 10/12/23 and Resident #8 was educated to pull the curtain for privacy during masturbation. SWD #301 stated Resident #8 had a right to privacy and freedom from abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 3 of 4 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 10/16/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/16/23 at 9:12 A.M. with the Director of Nursing (DON) revealed neither resident had ever shown signs of aggression. The DON stated the hospital stated no major injuries were sustained, only a laceration on Resident #8. Interview on 10/16/23 at 11:09 A.M. with the Director of Behavioral Health Psychologist #459 revealed Resident #8 was a quiet resident and never had problems with other roommates and Resident #7 was opinionated and religiously fixated, therefore, the masturbation bothered Resident #7 and provoked him against Resident #8 contributing to the fight. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, dated October 2022, documented the definition of abuse as the willful infliction of injury resulting in physical harm. The documented definition of willful as the means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH00147293. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365353 If continuation sheet Page 4 of 4