Deficiency Records for Candlewood Healthcare and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Candlewood Healthcare and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-16 | 2023-10-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-28 | 2023-03-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-28 | 2023-03-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-31 | 2023-03-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-31 | 2023-03-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-31 | 2023-03-22 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-09-20 | 2022-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-27 | 2022-11-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-27 | 2022-11-14 | N |
| 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. | Health | 2022-09-27 | 2022-11-14 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-09-27 | 2022-11-14 | N |
| 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. | Health | 2022-09-27 | 2022-11-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-27 | 2022-11-14 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-09-27 | 2022-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-27 | 2022-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-27 | 2022-11-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-31 | 2022-04-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-31 | 2022-04-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-31 | 2022-04-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-31 | 2022-04-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-31 | 2022-04-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-31 | 2022-04-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-31 | 2022-04-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-31 | 2022-04-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-31 | 2022-04-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-09 | 2022-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-09 | 2022-03-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-26 | 2022-03-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-26 | 2022-03-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-26 | 2022-03-03 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-01-05 | 2022-03-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-05 | 2022-03-03 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-01-05 | 2022-03-03 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-01-05 | 2022-03-03 | Y |
| Keep all essential equipment working safely. | Health | 2022-01-05 | 2022-03-03 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-28 | 2021-12-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-28 | 2021-12-03 | Y |
| 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. | Health | 2021-10-28 | 2021-12-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-28 | 2021-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-12-03 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-09-30 | 2021-12-03 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-06-23 | 2021-08-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-23 | 2021-08-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-23 | 2021-08-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-23 | 2021-08-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-23 | 2021-08-24 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-05-06 | 2021-05-31 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-05-06 | 2021-05-31 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-04-20 | 2021-05-31 | Y |
| 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. | Health | 2019-09-12 | 2019-12-09 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-09-12 | 2019-12-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-12 | 2019-12-02 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-09-12 | 2019-12-02 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-09-12 | 2019-12-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-12 | 2019-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-12 | 2019-12-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-12 | 2019-12-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-12 | 2019-12-02 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-09-12 | 2019-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-12 | 2019-12-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-12 | 2019-12-02 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-09-12 | 2019-12-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-12 | 2019-12-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-09-12 | 2019-12-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-12 | 2019-12-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-09-12 | 2019-12-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-09 | 2018-08-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-09 | 2018-08-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-09 | 2018-08-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-09 | 2018-08-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-08-09 | 2018-08-27 | N |
| 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. | Health | 2018-08-09 | 2018-08-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-09 | 2018-08-27 | N |
