Candlewood Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 31, 2026

  Based on interviews, observations, clinical record review, and review of facility policy for the only sampled resident reviewed for respiratory care (Resident #76), the facility failed to ensure a safe environment related to a resident self-administering a petroleum-based jelly while receiving continuous oxygen, creating a fire risk relating to oxygen speeding up combustion in the presence of oil based materials. Additionally, the use of petroleum-based products while receiving oxygen creates a risk of medical danger for aspiration pneumonia due to the potential for small particles being inhaled into the lungs from the petroleum product which over time can accumulate in the lungs causing inflammation of the lung tissue, chronic coughing and irreversible lung scarring. […]

• No harm, potential for more than minimal, patternF572Mar 31, 2026

  Based on review of facility documentation, resident council meeting minutes, facility policy, and interviews reviewed for Resident Council, the facility failed to ensure residents were informed of their rights, of all the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. The findings include: On 03/24/2026 at 1:32 PM, a Resident Council meeting was held with Residents #65, #75, #102, #103, #127, and #147 in attendance. The residents identified that facility staff had not reviewed or discussed Resident Rights with them. The residents further indicated they had not received education regarding facility rules or policies governing resident conduct and responsibilities. […]

• No harm, potential for more than minimal, patternF577Mar 31, 2026

  Based on observations, facility documentation review, facility policy review, and interviews reviewed for Resident Council, the facility failed to ensure the most recent surveys of the facility conducted by Federal or State surveyors were posted in a place readily accessible to residents, family members, and legal representatives of residents and failed to post notice of the availability of such reports in areas of the facility that are prominent and accessible. The findings include: A Resident Council meeting was held on 3/24/26 at 1:32 PM with Residents #65, #75, #102, #103, #127, and #147 in attendance. […]

• No harm, potential for more than minimal, patternF812Mar 31, 2026

  Based on a tour of the Dietary Department, observation, review of facility policy, and interview, the facility failed to ensure staff wore a beard guard (hair restraint) when assembling and serving food. The findings include:Observation of the meal service on 3/23/26 at 7:15 AM with the Dietary Director, identified:Dietary Aide #1 was observed at the steam table plating scrambled eggs, oatmeal, and toast onto residents' plates for meal delivery. Dietary Aide #1 had visible facial hair extending below the chin and was not wearing a beard restraint.Interview with the Dietary Director on 3/23/26 at 7:20 AM identified dietary staff are required to wear appropriate hair coverings, including beard restraints, when working in the kitchen and handling food. […]

• No harm, potential for more than minimal, patternF584Jun 7, 2024

  Based on observations, facility documentation and facility policy and interviews, the facility failed to ensure the environment was maintained in a safe secured manner on a locked unit for residents with special needs. The findings include: An observation of the facility memory care unit with the Director of Nursing Services and Assistant Director of Nursing Services on 6/06/24 at 12:35 PM identified the following: 1. One door labeled identified as the 'Soiled Utility' was unable to be fully closed, latched, and locked. 2. One door labeled 'Supply Room' was unable to be fully closed, latched, and locked. 3. One door labeled 'Clean Utility' was unable to be fully closed, latched, and locked. 4. […]