Inspection·February 8, 2024

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, interviews, review of facility food production sheets and diet type report, the facility failed to ensure Resident #18, #28, #38, #63, #85 and #94 received the pureed main entree in the proper portion size, failed to ensure Residents #19, #44, #49, #50, #60, #76, #77, #86 and #89 received the appropriate main entree for their low sodium diets as ordered, and failed to ensure Residents #13, #17, #21, #23, #25, #26, #30, #34, #41, #87, #91, #53, #54, #67, #69, #72, #73 and #79 received fortified foods as ordered. This affected a total of 33 residents of 94 residents receiving meals from the kitchen. The facility identified four residents (#2, #32, #65 and #74) as receiving nothing by mouth. The facility census was 98. Findings include: 1. Review of the facility food production sheet for lunch on 02/06/24 revealed residents on a puree diet were to receive two number eight scoops of pureed chili. Observation of the lunch tray line on 02/06/24 from 12:07 P.M. to 12:41 P.M. revealed residents who were on a puree diet received one number eight scoop of pureed chili from Dietary [NAME] (DC) #450 who was observed serving the pureed chili on the tray line. Interview on 02/06/24 at 12:34 P.M. with DC #450 confirmed he gave one number eight scoop of pureed chili to the residents on a puree diet. Review of the 02/06/24 lunch production sheet and interview with Dietary Manager on 02/06/24 at 12:57 P.M. confirmed the production sheet had not been followed and all residents on a puree consistency should have received two number eight scoops of pureed chili instead of one number eight scoop of puree chili. Review of the facility document titled Diet Type Report identified Residents #18, #28, #38, #63, #85 and #94 as having either pureed meat or pureed diet. 2. Review of facility food production sheet for lunch on 02/06/24 revealed residents on a low sodium diet were to receive one three-ounce hamburger on a bun with lettuce and onion instead of the chili. Observation of the lunch tray line on 02/06/24 from 12:07 P.M. to 12:41 P.M. revealed residents on a low sodium diet received one eight-ounce scoop of chili from DC #450. Interview on 02/06/24 at 12:34 P.M. with DC #450 confirmed he gave one eight-ounce scoop of chili (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365353 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 02/08/2024 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)