Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Candlewood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, vascular dementia, restlessness, and agitation, and severely impaired cognition had a care plan identifying combative behaviors with an intervention to stop care and reapproach later if the resident became aggressive or resistive. On one shift, during incontinent care, the resident became combative while two NAs attempted to provide care, and a family member assisted by holding the resident to prevent hitting staff so care could be completed. Staff interviews, including with an RN, confirmed that care was continued instead of stopping and reapproaching as directed by the care plan, resulting in a failure to provide care in accordance with the individualized plan.
The facility failed to maintain a secure environment in a memory care unit, as several doors, including 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were not fully closed, latched, or locked. The 'Shower' door was also unlocked. Interviews revealed that moisture prevented proper door closure, and the Director of Maintenance was unaware of the locking requirement. No facility policy for a safe environment was provided.
The facility failed to properly store and label medications, as observed in four medication carts. A resident's medication was not refrigerated as required, and two residents' medications were not labeled correctly on the Apple Blossom Unit. Additionally, an expired medication was found in the Dogwood unit. Staff interviews revealed a lack of adherence to facility policy, which mandates proper storage, labeling, and expiration checks.
The facility failed to maintain cleanliness in the laundry room, with vents and a smoke detector covered in debris. The Laundry Supervisor was unsure of the last cleaning date, and cleaning logs were not readily available. The IP/LPN confirmed that vents should be cleaned weekly, but the policy was not followed. A review of logs showed specific cleaning dates in May, but the June log lacked a specific date, only stating cleaning occurred on the surveyor's inquiry day.
Two residents experienced a lack of dignity and respect from a nurse aide (NA) who delayed assistance with toileting and raised her voice when addressed. One resident, with COPD and respiratory failure, reported the incident, but the facility failed to document a thorough investigation. The other resident, requiring total assistance due to hemiplegia, was left waiting for help, contrary to facility policy.
A resident with acute kidney failure and duodenitis experienced recurring diarrhea after admission to a facility. Despite the symptoms, the nursing staff failed to notify the physician in a timely manner. Interviews revealed communication lapses, with an LPN assuming the condition was documented and not reporting it to a supervisor or physician. The Medical Director was not informed of the recurrent episodes until later, contrary to facility policy.
A resident with Alzheimer's disease and severe cognitive impairment was struck in the chest by another resident with similar conditions in an unprovoked altercation. The incident was witnessed by an LPN, who confirmed no prior signs of agitation. The facility's policy requires intent to harm for abuse classification, but the incident was reported, and the involved resident was placed under observation and sent for evaluation.
A resident with Alzheimer's and insomnia was not administered medications as prescribed, as pills were found in their nightstand drawer. Despite no swallowing disorders, the resident was at risk for aspiration and required a ground diet. Staff interviews revealed that oral checks to confirm medication ingestion were not consistently performed, although it was a standard practice learned during nursing education.
A resident with acute kidney failure and duodenitis experienced diarrhea and gastric upset after eating shrimp, but the nursing staff did not report the change of condition to a supervisor or physician. Additionally, the resident had a nosebleed that was not followed by a documented nursing assessment. The facility lacked a policy for RN assessments, leading to a deficiency in care.
A resident with multiple health conditions, including diabetes and cancer, developed new pressure wounds, but the facility failed to reassess their nutritional status. Despite weekly discussions with the interdisciplinary team, the Dietitian was unaware of the new wounds and did not conduct a reassessment, contrary to the facility's policy on pressure injury management.
Two residents experienced deficiencies in respiratory care due to improper storage of equipment. A resident with COPD had a nebulizing mouthpiece left uncovered, while another with sleep apnea had a CPAP mask and oxygen tubing improperly stored. Staff interviews confirmed the equipment should have been stored in bags, but the facility's policy was not provided.
A facility failed to re-evaluate the use of PRN Lorazepam for a resident with anxiety disorder, Major Depressive Disorder, and vascular dementia. Despite the resident's behavioral records showing no change, the medication was administered without documented review or justification. Staff interviews revealed inconsistencies in managing PRN psychotropic medications, and the facility's policy did not address medication use requirements.
The facility failed to honor the food preferences of two residents, leading to deficiencies in care. One resident, with diverticulitis and atherosclerosis, wanted eggs and hash browns more often than provided, but the facility did not consistently accommodate this preference. Another resident, with macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite indicating a dislike for it. The facility's dietary policy and Residents' Rights emphasize accommodating preferences, yet these were not consistently followed.
A facility failed to provide a resident's medical records within 48 hours as required. The resident, who had cognitive impairment and required assistance with daily activities, had a family member request discharge paperwork. The social worker miscommunicated the process, directing the family to the acute care facility for records. Additionally, the medical records staff could not recall or find documentation of the request, violating the facility's policy for timely access to records.
A resident's family member was overcharged for copies of medical records, with inconsistencies in the rates quoted by facility staff. The facility's administrator was unaware of the overcharge, which exceeded the state statute and facility policy limits.
Failure to Follow Care Plan Interventions for Combative Resident During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care in accordance with an existing care plan and to follow care plan interventions when a resident became combative and resistive to care. Resident #1 had diagnoses including Alzheimer’s disease, vascular dementia, restlessness, and agitation, and a quarterly MDS showed a BIMS score of 1, indicating severely impaired cognition, dependence for ADLs, and no documented behaviors in the prior seven days. The resident’s care plan, dated 2/2/26, identified combative behaviors and directed staff that if the resident became aggressive or resistive to care, they were to leave the resident if safe to do so and reapproach later. Facility policy on care planning directed development of an appropriate and individualized plan of care for residents. On 4/4/26, a nursing note documented that Resident #1 was combative with incontinent care at the start of the shift. During surveyor interviews, NA #1 reported that around 3–4 PM that day, Resident #1 was combative while NA #1 and NA #3 attempted to provide incontinent care, and that a family member assisted by helping to hold the resident to prevent the resident from hitting staff so that care could be completed. Interview with RN #1 confirmed that the resident was combative during care around 4 PM and that staff should have stopped care and reapproached later when the resident became combative. The DON and Administrator acknowledged the resident had a history of being combative during care and stated that if the resident was combative, staff should ensure the resident’s safety, leave, and attempt to reapproach later. These accounts show that staff did not follow the care plan intervention to stop and reapproach when the resident became combative.
Failure to Secure Doors in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe and secure environment on a locked memory care unit for residents with special needs. During an observation, it was found that several doors, including those labeled 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were unable to be fully closed, latched, and locked. Additionally, the 'Shower' door was not locked. Although there were no accessible sharps or hazardous materials in these rooms and no residents were in the immediate area, the doors were expected to remain securely locked. Interviews with the Director of Nursing Services confirmed that the doors should have been locked, and the Director of Maintenance identified moisture as the reason for the doors not closing properly. The Director of Maintenance was not previously aware of the requirement for the doors to be locked. The facility did not provide a policy for ensuring a safe and secure environment when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to professional standards and facility policy, as observed in four out of seven medication carts. On the Elm Tree unit, a medication prescribed to a resident was not stored in the refrigerator as required after opening, and the Licensed Practical Nurse (LPN) was unsure of when it was opened. The medication was last administered the previous evening, and the LPN acknowledged that medications should be stored according to directions, with the last nurse responsible for proper storage. On the Apple Blossom Unit, two residents' medications were not labeled correctly. One resident's inhaler was not labeled at all, and another resident's medication lacked a date indicating when it was opened. The Registered Nurse (RN) interviewed was unable to explain the labeling issue and stated that the pharmacy is responsible for labeling, while staff should check orders before administration. Additionally, in the Dogwood unit's medication room, a resident's medication was found to be expired. The LPN interviewed confirmed that expired medications should be reviewed and discarded, and nurses are responsible for checking expiration dates. The facility's policy requires medications to be stored in pharmacy-labeled containers, with opened medications dated and refrigerated if necessary.
Laundry Room Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the laundry room, as observed during a tour on June 5, 2024. Two vents and a smoke detector were found covered in gray debris, with one vent located in the dirty laundry area and the other in the clean laundry area near a folding table. The smoke detector was also in the clean laundry area. During an interview, the Laundry Supervisor admitted uncertainty about the last cleaning date and mentioned that cleaning logs were not readily available in the laundry area. The Infection Preventionist (IP)/LPN confirmed that the vents should be cleaned weekly by the laundry aide and that cleaning logs exist, but was unsure why the policy was not followed. A review of the cleaning logs for May and June 2024 revealed that the vents were cleaned on specific dates in May, but the June log lacked a specific date, only stating that the vents were cleaned on the day of the surveyor's inquiry. The facility's policy, dated February 20, 2024, directed that vents be cleaned weekly, which was not adhered to.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the actions of a nurse aide (NA #1) towards two residents. Resident #23, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), emphysema, and chronic respiratory failure, required supervision and assistance with activities of daily living (ADL). Despite being cognitively intact and able to make needs known, Resident #23 reported that NA #1 raised her voice when asked to assist another resident, Resident #30, who needed to use the bathroom. This incident was reported to the nursing supervisor (RN #2), but there was no documented investigation attached to the grievance report. Resident #30, diagnosed with weakness, hemiplegia, and hemiparesis, required total assistance with toileting and was non-ambulatory. On the day of the incident, Resident #30 requested assistance from NA #1 to use the bathroom. NA #1, who was busy clearing trays, told Resident #30 to wait and did not inform another staff member to assist. It was only after Resident #23 intervened that NA #1 assisted Resident #30, approximately 15 minutes after the initial request. This delay in assistance and the manner in which NA #1 responded to the residents were not in line with the facility's policy to treat residents with care, courtesy, and respect. The facility's grievance policy requires a prompt and thorough investigation of all grievances, which was not adhered to in this case. The nursing supervisor acknowledged the incident as a customer service issue but failed to document the investigation properly. The lack of documentation and the failure to prioritize resident needs, such as toileting assistance, contributed to the deficiency in maintaining resident dignity and rights.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in status for Resident #427, who was exhibiting recurring symptoms of diarrhea. Resident #427, who had been diagnosed with acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing loose stools and requested medication for relief. Despite these symptoms, there was no documentation of how the change in condition was addressed, and the physician was not notified in a timely manner. Interviews with various nursing staff revealed a lack of communication and reporting regarding the resident's condition. LPN #6, who was on duty during the episodes of diarrhea, did not report the change of condition to a nursing supervisor or physician, believing it was already documented in the APRN communication book. The Medical Director was not informed of the recurrent episodes until later, and the Director of Nursing Services expected that any change of condition should be reported. The facility's policy directed that significant changes in status should be reported to the Nursing Supervisor, which was not followed in this case.
Resident-to-Resident Altercation in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse during a resident-to-resident altercation. Resident #48, who has Alzheimer's disease and severe cognitive impairment, was struck in the chest by another resident, Resident #75, who also has Alzheimer's disease and severe cognitive impairment. The incident occurred while Resident #48 was walking in the hallway with another person. Resident #75, who had no prior history of aggression, unexpectedly hit Resident #48 and yelled profanities. The altercation was witnessed by LPN #4, who confirmed that there was no provocation or signs of agitation from either resident prior to the incident. The facility's policy defines resident-to-resident altercation as a physical or verbal act between two residents, regardless of injury. The policy also states that cognitively impaired residents must possess intent to harm for an act to be considered abuse. Despite this, the incident was reported, and the supervisor, physician, and police were notified. Resident #75 was placed on 1:1 observation and sent to the hospital for evaluation following the altercation.
Failure to Ensure Proper Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #48, was administered medications as prescribed by the physician and in accordance with professional practice standards. Resident #48, who had diagnoses including Alzheimer's disease and insomnia, was found to have severe cognitive impairment and required assistance with personal hygiene and dressing. Despite having no swallowing disorders, the resident was at risk for aspiration and was on a ground diet consistency. The care plan included administering psychotropic medications as ordered and monitoring the resident's behaviors and sleep. However, an internal investigation revealed that pills, which were supposed to be administered to the resident at bedtime, were found in the resident's nightstand drawer. These pills included Melatonin, paroxetine, donepezil, quetiapine, and memantine. Interviews with staff indicated that the pills were identified by their appearance and imprints, and it was suspected that the resident may have had the pills in their mouth and spit them out. The facility acknowledged that ensuring cognitively impaired residents take their medications completely is part of the standard of practice. Despite this, it was noted that oral checks to confirm medication ingestion were not consistently performed. An LPN confirmed that checking if a resident swallowed their medications properly was a standard practice learned during nursing education. Observations during a medication pass showed that oral checks were performed, but not all staff had participated in the in-service training on oral checks, highlighting a gap in consistent practice across the facility.
Failure to Conduct Nursing Assessment for Change of Condition
Penalty
Summary
The facility failed to ensure a nursing assessment was completed for a resident experiencing a change of condition. Resident #427, who had diagnoses including acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing symptoms of diarrhea and gastric upset after consuming shrimp. Despite the resident's request for medication to address these symptoms and documentation in the APRN communication book, the nursing staff did not report the change of condition to a nursing supervisor or physician. Interviews revealed that the nursing staff believed the symptoms were food-related and did not require further reporting or assessment. Additionally, the resident experienced an episode of epistaxis, which was noted in the shift report but not followed by a documented nursing assessment. The Director of Nursing Services indicated that any change of condition should be reported and assessed, but this protocol was not followed. The lack of a policy for RN assessments was noted, and interviews with nursing staff confirmed that the change of condition was not communicated to the appropriate personnel, leading to a deficiency in care.
Failure to Reassess Nutritional Needs for Resident with New Pressure Wounds
Penalty
Summary
The facility failed to reassess the nutritional status and needs of a resident with newly identified pressure wounds. Resident #103, who had diagnoses including type II diabetes mellitus, obstructive sleep apnea, and malignant neoplasm of the urethra/bladder, was identified as being at risk for pressure ulcers. Despite the presence of unhealed pressure ulcers and the development of new wounds on the left ankle, sacrum, right hip, and right knee, there was no documented reassessment of the resident's nutritional status following these developments. The resident was receiving palliative care, and while some nutritional interventions were noted, such as the addition of liquid protein, the lack of a formal reassessment was a significant oversight. Interviews with the Dietitian and the Director of Nursing Services (DNS) revealed that wounds were discussed weekly with the interdisciplinary team, including the Dietitian. However, the Dietitian was unaware of the new wounds and had not conducted a reassessment of the resident's nutritional needs. The facility's policy for Pressure Injury Prevention and Management required that residents at high risk for pressure injuries or with existing pressure injuries receive appropriate interventions, and that the plan of care be revised as necessary. The failure to reassess the nutritional needs of Resident #103 following the identification of new wounds was a deviation from this policy.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and maintenance of respiratory equipment for two residents, leading to deficiencies in respiratory care. Resident #71, diagnosed with chronic obstructive pulmonary disease and essential hypertension, was observed with a nebulizing mouthpiece left uncovered on top of the nebulizing equipment. Despite having a care plan that included nebulizer treatments, the mouthpiece was not stored in a bag after use, as confirmed by a registered nurse who admitted to the oversight. The Director of Nursing Services and the registered nurse both acknowledged that all respiratory equipment should be stored in a bag when not in use. Resident #103, who has obstructive sleep apnea, was found with a CPAP mask placed on top of the machine without a cover and oxygen tubing labeled with an outdated date. The resident used the CPAP during the night and oxygen during the day, but the equipment was not stored properly when not in use. Interviews with a nurse aide and the Director of Nursing Services confirmed that the CPAP mask and oxygen tubing should have been stored in a bag and changed weekly, respectively. The facility's policy for storage guidelines was not provided, contributing to the deficiency.
Failure to Re-evaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the re-evaluation of a psychotropic medication for a resident diagnosed with anxiety disorder, Major Depressive Disorder, and vascular dementia. The resident, who was cognitively impaired and required maximal assistance with daily activities, had a physician's order for Lorazepam to be administered every four hours as needed for restlessness and agitation. Despite the medication being prescribed on a PRN basis, the facility did not provide documentation or rationale for the continued use of this medication. The resident's behavioral flow records indicated no change in behaviors, yet the PRN Lorazepam was administered without a documented review or justification. Interviews with facility staff revealed inconsistencies in the management and documentation of PRN psychotropic medications. An RN indicated that PRN orders should be reevaluated every 14 days, while an LPN noted that targeted behaviors and interventions should be documented when psychotropic medications are used. However, the facility's policy on psychotropic medication did not address the requirements for medication use, and there was no rationale provided for the continued PRN order for Lorazepam. The facility's DNS mentioned that psychotropic medications are not usually prescribed as PRN, highlighting a lack of adherence to the facility's usual practices.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to deficiencies in their care. Resident #121, who has diagnoses including diverticulitis and atherosclerosis, expressed a preference for eggs and hash browns more frequently than the once-weekly offering. Despite communicating this preference to the dietary staff, the Food Service Director stated that eggs could not be provided more often due to preparation constraints, and hash browns were not consistently set aside for the resident. The Director of Nursing Services acknowledged the resident's numerous preferences and expected reasonable accommodations, but the facility did not ensure these preferences were consistently met. Resident #52, with diagnoses including macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite expressing a dislike for it and indicating this preference on meal tickets. The Kitchen Supervisor acknowledged the issue, attributing it to confusion among new staff, which led to the resident receiving incorrect meals. The facility's dietary notice policy and the Residents' Rights emphasize the importance of accommodating individual preferences, yet these were not adhered to, resulting in the residents' preferences being overlooked.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide copies of a resident's medical record within the required 48-hour timeframe. This deficiency was identified during a review of the clinical records, facility policy, and staff interviews for a resident who was admitted with multiple diagnoses, including metabolic encephalopathy and cognitive impairment. The resident required substantial assistance with daily activities, as noted in their care plan. A family member, identified as the resident's emergency contact, requested a copy of the resident's discharge paperwork. However, the social worker informed the family member that they could not provide the paperwork and directed them to the acute care facility for the records. Further investigation revealed inconsistencies in the facility's handling of the request. The social worker later clarified that the request was for medical records from the acute care facility, not the discharge paperwork from the facility, and stated that the facility's policy required the family to obtain records from the outside facility. Additionally, a staff member from the medical records department could not recall receiving any request for copies of the resident's medical record and found no documentation of such a request. The facility's policy allows residents or their legal representatives to access and purchase copies of their records within two working days of the request, which was not adhered to in this case.
Inappropriate Charges for Medical Record Copies
Penalty
Summary
The facility failed to charge the appropriate amount for copies of a resident's medical records, leading to a deficiency in compliance with applicable laws and regulations. Resident #432, who was admitted with diagnoses including metabolic encephalopathy, essential hypertension, muscle weakness, hypothyroidism, and dysphagia, was identified as cognitively impaired and required substantial assistance with activities of daily living. The resident's family member, who was the emergency contact, requested copies of the medical records and was charged 75 cents per page and an additional 30 dollars for document retrieval. Interviews with facility staff revealed inconsistencies in the charges for medical record copies, with different staff members quoting different rates per page, none of which aligned with the Connecticut general state statute. The facility's administrator acknowledged that residents or family should not be charged more than 65 cents per page and was unaware of the reason for the overcharge. The facility's policy stated that the cost for copies should not exceed prevailing community rates, indicating a failure to adhere to their own policy and state regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Milford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Crest Center For Health & Rehabilitation | 1 mi | — | 0 | 0 |
| The Grand Rehabilitation And Nursing At Pawling | 9.8 mi | — | 0 | 0 |
| Springs At East Hill, The | 11.3 mi | — | 0 | 0 |
| Lutheran Home Of Southbury Inc | 11.8 mi | — | 3 | 0 |
| Pomperaug Woods Health Center | 11.9 mi | — | 0 | 0 |
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