Candlewood Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Candlewood Healthcare and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 1, 2024

  Based on observation, medical record review, Self-Reported Incident (SRI) review, witness statement review, policy review and interview, the facility failed to ensure Resident #64 and Resident #93 were free from incidents of physical abuse by Resident #50. This affected two residents (Resident #64 and #93) of six residents reviewed for abuse. Actual harm occurred on 09/24/24 when Resident #93 was physically abused/assaulted by Resident #50 resulting in an injury. At the time of the incident, Resident #50 punched, with a closed fist, Resident #93, unprovoked, resulting in Resident #93 experiencing pain rated a seven out of 10 (on a pain scale with 10 being the most severe pain), headache, distress with crying resulting in a transfer to the hospital emergency department where the resident… […]

• Actual harm, isolatedF600Feb 28, 2023

  Based on record review, review of a facility self-reported incident, facility policy review and interview the facility failed ensure a smoking privilege was not withheld as a punishment for Resident #71 and failed to ensure the resident was free from an incident of staff to resident abuse. Actual Harm occurred on 02/17/23 when facility staff withheld smoking as a punishment for Resident #71 which then escalated to an altercation between State tested Nurse Aide (STNA) #563 Resident #71. STNA #563 was observed to pin Resident #71 against the wall causing the resident to be fearful of the aide and upset/crying resulting in psychosocial harm. This affected one resident (#71) of three residents reviewed for abuse. […]

• No harm, potential for more than minimal, widespreadF812Feb 8, 2024

  Based on observation and interviews, the facility failed to ensure kitchen employees were wearing beard guards while preparing and serving food, and failed to ensure drinks on resident meal trays were covered while carrying the trays through the hallways for delivery to the residents. This had the potential to affect all 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. Observation on 02/01/24 from 12:20 P.M. to 12:25 P.M. revealed State tested Nursing Assistant (STNA) #336 poured lemonade and fruit punch into plastic cups in an area around the nurse's station and then placed the cups of liquid back onto the meal trays in the covered food cart. […]

• No harm, potential for more than minimal, widespreadF800Sep 27, 2022

  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. […]

• No harm, potential for more than minimal, widespreadF801Sep 27, 2022

  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. […]