F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
Review of the medical record for Resident #2 revealed an admission date of 09/08/23 with diagnoses of
cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, vascular dementia with
mood disturbance, diabetes, gastrostomy, chronic heart failure, anxiety disorder, depression, psychosis and
suicidal ideations.
Review of the general note dated 04/15/24 revealed Resident #2 was alert and oriented times two and
pleasant. He was able to make his needs known to staff. He utilized a Hoyer (mechanical lift) for transfers
and two-person maximum assistance with all other activities of daily living. He was incontinent of bowel and
bladder. He was NPO (nothing by mouth) and was tolerating continuous tube feedings.
Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #2 was
cognitively intact, had hallucinations and delusions, was dependent on staff for oral and personal hygiene,
toileting, bathing, upper and lower body dressing, and bed mobility.
Observation on 06/17/24 at 9:15 A.M. revealed Resident #2 was lying in bed, in a hospital gown, on his
back, asleep, with a feeding tube. Interview, during the observation, with Resident #2 revealed he had a
complaint that one of the workers bent his right arm back and cut his fingernails when he told her not to do
it. The incident occurred approximately four months ago, and he told a nurse or someone about it but he
couldn't remember the name of the person he reported the incident to. Resident #2 stated my arm hurts as
he held up and bent his right arm at the elbow.
Interview on 06/17/24 at 10:00 A.M. with State-tested Nurse Aide (STNA) #4 revealed Resident #2 did
make an allegation of abuse towards STNA #3 saying, she abused him by pulling his arm, and he asked
STNA #3 to stop but she didn't. The incident occurred approximately a couple of weeks ago/a month ago.
STNA #4 notified former Registered Nurse (RN) #7 of the allegation.
Interview on 06/17/24 at 10:28 A.M. with the Administrator and the Director of Nursing (DON) revealed RN
#7 hadn't worked at the facility since 02/10/24. The Administrator and the DON were unaware of Resident
#2's physical abuse allegation towards STNA #3.
(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 2
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
06/17/2024
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 06/17/24 with Resident #2's Power of Attorney (POA) revealed STNA #3 was rough with
Resident #2 and would hold him down and talk smack to him. Resident #2's POA reported the incident to
the Scheduler and Case Manager; however, Resident #2's POA was unable to remember the staff names.
Interview on 06/17/24 wat 11:25 A.M. with Regional Clinical Support Nurse (RCSN) #9 with the
Administrator and DON present, revealed former Administrator/Regional Administrator #10 was also
unaware of a physical abuse allegation involving Resident #2 and STNA #3. RCSN #9, the Administrator
and the DON all verified it was the expectation and facility policy for the Administrator to be immediately
notified a resident abuse allegation.
Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident
Property policy dated October 2022 revealed staff should report all incidents/allegations immediately to the
Administrator or designee. If a staff member is accused or suspected, the facility should immediately
remove that staff member from the facility and the schedule pending the outcome of the investigation. All
incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of resident
property and all injuries of Unknown Source must be reported immediately to the Administrator or
designee. The Administrator/designee should be notified by informing him/her in person, calling via
telephone, or sending an email or text message.
This deficiency represents non-compliance investigated under Master Complaint Number OH00154585 and
Complaint Number OH00154530.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365353
If continuation sheet
Page 2 of 2
