Candlewood Healthcare and Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #96's resident fund account was dispersed timely following the resident's discharge from the facility. This affected one resident (Resident #96) of five residents reviewed for funds. The facility census was 88.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure staff followed infection control standards to prevent cross contamination during tracheostomy (a tube in the opening of the trachea for breathing) care. This affected one (Resident #76) of one resident reviewed for tracheostomy care. The facility census was 88.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, medical record review, Self-Reported Incident (SRI) review, and interview, the facility failed to develop a care plan with individualized interventions to support the behavioral health care needs of Resident #50, who had diagnoses of major depressive disorder, schizophrenia, generalized anxiety disorder, schizoaffective disorder, mood disorder, obsessive compulsive disorder and psychosis. This affected one (Resident #50) of six residents reviewed for behavioral health care needs.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure a staff-to-resident physical abuse allegation involving Resident #2 was reported to the Administrator. This affected one resident (#2) of five residents reviewed for abuse. The census was 99.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, review of the facility Self-Reported Incident (SRI) investigation, review of policy, observations and interviews, the facility failed to ensure Resident #7 and Resident #8 were free from physical abuse. This affected two residents (Resident #7 and #8) out of three residents reviewed for abuse. The facility census was 92.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, observation, and interviews the facility did not ensure food was served at palatable temperatures 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.

Inspectors wroteBased on observations, interview, record review, and facility policy review the facility failed to ensure proper ware washing and a clean and sanitary kitchen. 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.

Inspectors wroteBased on observation, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure tuberculin purified protein derivative (PPD) and sodium bicarbonate were stored according to manufacture guidelines. This had the potential to effect five (Resident's #8, #14, #20, #57 and #286) who were admitted in the last 30 days and three (Resident's #35, #42, and #62) who received sodium bicarbonate. The facility census was 81.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure medications were not left unattended at the resident's bedside. This affected one (Resident #44) of 82 residents observed for environmental safety. The facility census is 82.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure a medication error rate of less than 5%. Two errors were observed in 33 opportunities resulting in a 6.06% medication error rate. This affected two (Resident's #58 and #81) of six (Resident's #4, #6, #44, #58, #61 and #81) observed for medication administration. The facility census was 82.

Inspectors wroteBased on observation, medical record review, staff interviews, and facility policy review the facility failed to ensure residents were provided with adaptive equipment to maintain independence while eating. This affected three (Resident's #11, #39 and #81) of eight residents (Residents #4, #8, #11, #25, #39, #51, #67 and #81) who received adaptive eating equipment. The facility census was 82.

Inspectors wroteBased on observations, record review, staff interview, and facility policy review the facility failed to ensure proper infection control during glucose monitoring. This affected one (Resident #6) of five (Resident's #6, #13, #22, #31 and #45) who received glucose monitoring on the second-floor east unit. The facility census was 82.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were delivered in a timely manner in accordance to the posted meal times. This affected 109 out of 112 that ate meals in the facility. Residents #37, #52 and #70 received nothing by mouth. The facility census was 112.

Inspectors wroteBased on record review and staff interview the facility failed to maintain a clean and sanitary environment. This affected all residents. This affected all 75 resident occupied rooms. The facility census was 112. Findings Include: 1. Observation of Resident #95's room on 09/09/19 at 9:15 A.M. revealed dried fecal matter on the floor and toilet seat. The facilities Administrator verified the dried fecal matter at the time of discovery. 2. Observation of Resident #4 on 09/09/19 at 11:00 A.M. revealed Resident #9 was laying perpendicular in her bed and significant areas of dried blood were noted on the sheet of the bed. Licensed Practical Nurse #100 verified the blood stains at the time of discovery. 3. An environmental tour was conducted on 09/10/19 between 9:22 A.M. and 10:09 A.M. with Maintenance Director #901. The following was observed and verified at the time of discovery. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain a call light system that was readily accessible to all its residents. This affected 17 (Residents #2, #11, #24, #39,#43, #46 #59, #61,#66 #67, #79 #82, #90, #94, #96, #162, #261) of 112 Residents. The facility census was 11 1. Resident #24 was admitted to the facility on [DATE] with diagnoses including schizophrenia, major depressive disorder and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was moderately cognitively impaired and required assistance of one person for activities of daily living. Observation of Resident #24 on 09/09/19 at 10:54 A.M. revealed Resident #24 was laying in bed. Resident #24's call light was observed to be on the floor. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure medications were stored in a secured manner. This affected the 44 residents (Residents #4, #14, #15 #17, #20, #21, #25, #26 #28, #29, #30, #37, #38, #39 #42, #44, #47, #49, #52, #55, #60, #62, #64, #69 #70, #71, #72, #73, #75, #77, #78, #81, #83, #86, #88,#91, #92, #95, #97, #102, #104, #105, #311 and #312.) who resided on the first floor and the two south unit. This affected and two of three medication carts observed. The facility census was 112. Findings Include: 1. Observation of the first floor nurse's medication cart on 09/12/19 between 10:44 A.M. and 11:00 A.M. with Registered Nurse (RN) #944 revealed three unidentified loose pills at the bottom of multiple drawers through out the medication cart. RN # 944 verified the findings in an interview on 09/12/19 at 11:00 A.M. 2. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 109 out of 112 residents who ate meals in the facility's kitchen. Three Residents (#37, #52 and #70) received nothing by mouth. The facility census was 112. Finding Include: Interviews by the survey team were made on 09/09/19 between the hours of 8:45 A.M. and 3:00 P.M., Residents #14, #42, #49, #101 and #106 revealed that the food was not served at a palatable temperature. Interviews during the annual survey's resident council on 09/11/19 at 2:30 P.M., Residents #16, #42, #88, #103 and #107 revealed that the food was not served at a palatable temperature many of the meals. On 09/11/19 at 12:05 P.M. a test tray was requested due to multiple complaints about the temperature of the food. The food truck left the kitchen at 1:02 P.M. [...]

Inspectors wroteBased on observation, taste test and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected eight out of eight residents (#7, #19, #20, #34, #44, 60, #83, and #85) who were prescribed a pureed diet of 109 residents who consumed meals from the facility's kitchen. Residents #37, #52 and #70 received nothing by mouth. The facility census was 112.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This affected 109 out 112 residents who received meals from the dietary department. Resident #37, #52, and #72 were Nothing by Mouth (NPO) and did not receive meals prepared by dietary staff. The facility census was 112.

Inspectors wroteBased on observation and staff interview the facility failed to ensure its kitchen were free from pests (flies) by having an affective pest control system. This had the potential to affect 109 of 112 residents in the facility. The facility census was 112.

Inspectors wroteBased resident and staff interview the facility failed to obtain written authorization from the resident or responsible party prior to managing a residents personal funds. This affected one (Residents #12) of eight resident accounts reviewed This had the potential to affect all residents that have accounts. The facility census was 112. Findings Include: Residents #12 was admitted to the facility on [DATE] with diagnoses that included, schizophrenia, type two diabetes and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 cognitively intact. Review demographic information Resident #12 revealed he was his own responsible party. Review of the business office file for Resident #12 noted monthly deposits of 300$ entitled private sector ck deposited into an account managed by the facility. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #164) of one residents reviewed for funds conveyance. The facility census was 112. Findings Include: Resident #164 was admitted to the facility on [DATE]. Resident #124 expired at the facility on [DATE]. Review of the business records for Resident #164 revealed two separate checks for $21.75 and $1,000 dollars were dispersed to the funeral home handling Resident #164's arrangements on [DATE]. Business Manager #300 verified that Resident #164's funds were conveyed outside of required timeframes (30 days) in an interview on [DATE] at 1:35 P.M.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure a level two pre admission screen and resident review (PASRR) assessment was completed timely as required. This affected one (Resident #76) of two residents reviewed for PASRR status. The facility census was 112 Findings Include: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to assess resident blood glucose levels in a timely manner. This affected one (Resident #91) of 27 residents who receive blood glucose testing (Resident #73, #102, #44, #311, #17, #81, #42, #78, #4, #92, #105, #95, #22, #106, #12, #10, #2, #60, #94, #90, #16, #24, #13, #101, #48, #32, and #91). The total census was 112.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the physician's diet order was followed for Resident #30. This affected one resident (Resident #30) out of four (Residents #10, #30, #52 and #77) reviewed for nutrition. The facility census was 112.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper infection control when administering medications and blood glucose tests. This affected one (Resident #81) of two (Resident #81 and #311) residents on IV (intravenous) medications, and one (Resident #91) of 27 residents who receive blood glucose testing (Resident #73, #102, #44, #311, #17, #81, #42, #78, #4, #92, #105, #95, #22, #106, #12, #10, #2, #60, #94, #90, #16, #24, #13, #101, #48, #32, and #91). The total census was 112.