Sandwich Living & Rehab Center

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a safe environment by ensuring a resident's previous room was locked while being repaired. This applies to 1 of 3 residents (R2) reviewed for safety in the sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure catheter care was completed in a manner to prevent contamination for a resident with a history of urinary tract infections (R4), for 1 of 3 residents reviewed for indwelling urinary catheters in the sample of 4.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure water in resident rooms and a shower room used by residents was at a safe temperature. On 2/2/26 at 10:42 AM the bathroom sink in R3's room had a water temperature measuring 149.5 degrees. The South Shower Room shower water measured 146.5 degrees and the water in R17's bathroom sink measured 145.5 degrees. This has the potential to affect all 13 of 13 residents (R1, R3, R4, R5, R7, R13, R15, R17, R19, R21, R24, R30, R36) residing on the South Hall of the facility reviewed for safety. The Immediate Jeopardy began on 2/2/26 when the water temperatures on the South Hall measured between 145 and 153.5 degrees Fahrenheit. V1 (Administrator) was notified of the Immediate Jeopardy on 2/3/26 at 12:30PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe walking environment for a resident at risk for falls for 1 of 3 residents (R3) reviewed for falls in the sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the dining room floor in a safe, functional condition for 9 ambulatory residents (R2, R3, R4, R6, R7, R8, R9, R10, R11) reviewed for a safe, functional environment in the sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify a wound prior to becoming a deep tissue injury (DTI), failed to ensure pressure ulcer interventions were in place, and failed to ensure weekly wound assessments were done for 2 of 5 residents (R11, R19) reviewed for pressure ulcers in the sample of 13. These failures resulted in R11 being at an increased risk of infection and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent an unplanned, significant weight loss for 1 of 2 residents (R8) reviewed for nutrition in the sample of 13. This failure resulted in R8 sustaining a 7.98% weight loss over 1 month.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a comfortable home like dining experience for two of three residents (R21 and R7) reviewed for clean, comfortable homelike in the sample of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner (R8) and failed to ensure a resident was assessed for safe smoking (R18) for 2 of 4 residents reviewed for safety in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an indwelling catheter drainage bag was maintained in a manner to prevent contamination for 1 of 3 residents (R4) reviewed for catheters in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to initiate an antibiotic when ordered for 1 of 1 residents (R19) reviewed for pharmacy services in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 25 opportunities with two errors resulting in a 8% error rate. This applies to one of four residents (R23) observed in the medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to use the current electronic health records (EHR) medication administration record (MAR) to administer medications to the residents. This applies to 3 of 3 residents (R21, R18 and R23) reviewed for medical records in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to implement EBP (enhanced barrier precautions) for 3 of 6 residents (R4, R11, R19) reviewed for infection control in the sample of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free of physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in R1 being punched in the face by R2.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's Healthcare Power of Attorney (HPOA) regarding medication and weight changes. This applies to 1 of 3 resident (R4) reviewed for notification in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and notify the physician of a new wound. This applies to 1 of 3 residents (R4) reviewed for wound care in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform weekly assessments for pressure wounds. This applies to 2 of 3 residents (R5, R6) reviewed for wounds in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent residents from smoking in the facility and failed to ensure residents at risk for elopement do not exit the facility for 3 of 3 residents reviewed (R1, R2, R3) reviewed for safety in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's were free from physical abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's physician orders were followed for 1 of 3 residents (R3) reviewed for physician orders in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to document a change of condition and death for 1 of 3 residents (R1) reviewed for death in the sample of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and document a residents change of condition and failed to obtain daily weights as ordered for 2 of 3 residents (R1, R2) reviewed for nursing care and assessments in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an altered diet for a resident with dysphagia for 1 of 3 residents (R6) reviewed for therapeutic diets in the sample of 22. This failure resulted in R6 experiencing a choking episode requiring the Heimlich Maneuver and abdominal thrusts to dislodge. The Immediate Jeopardy began on 4/26/24 when an order was received to downgrade R6's diet from regular consistency to a mechanical soft consistency and R6 continued to be served a regular diet. V18 (Registered Nurse) was notified of the Immediate Jeopardy on 6/28/24 at 11:10 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/28/24 at 3:47 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menus were reviewed by a dietitian. This applies to all 28 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored in a safe and sanitary manner. This has the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of drug diversion. This applies to 5 of 6 (R2, R7, R8, R9, R14) residents reviewed for misappropriation of resident property in the sample of 14.

Inspectors wroteBased on interview and record review the facility failed to have policies in place to show accurate reconciliation of controlled substances, failed to implement current policies for the accurate reconciliation of controlled substances, failed to ensure controlled substance records are maintained, and failed to ensure controlled substances are periodically reconciled. This applies to 6 of 6 residents (R2, R7, R8, R9, R12, and R14) reviewed for controlled substances in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the building to provide a safe and comfortable environment. This applies to 12 of 12 residents (R2, R3, R4, R8, R10, R12, R15, R18, R19, R20, R21, R22) reviewed for functional and safe environment.

Inspectors wroteBased on interview and record review the facility failed to prevent the diversion of Schedule II medication. This applies to 2 of 6 (R2, R7) residents reviewed for misappropriation of resident medications in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions for a resident experiencing significant weight loss for 1 of 4 residents (R8) reviewed for weight loss in the sample of 17. This failure resulted in R8 experiencing a 19.47% weight loss from 11/23/23 to 1/24/24 (2 months and 1day.)

Inspectors wroteBased on interview and record review, the facility failed to have licensed nursing coverage 24 hours a day. This failure has the potential to affect all 27 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked at least 8 hours a day. This has the potential to affect all 27 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the bucket used for wiping down the dining room tables had the correct amount of chemical level to achieve sanitation; the facility failed to ensure food temperatures remained at 135 degrees Fahrenheit or above, prior to serving; the facility failed to prevent cross-contamination during the lunch meal service; and the facility failed to ensure temperature and sanitation logs were completed. This has the potential to affect all 27 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to continue testing residents and staff for Covid-19 until there was no positive cases for 14 consecutive days, and failed to notify the local health department of a Covid-19 breakout. This has the potential to affect all of the 27 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident background checks were completed for 3 of 5 residents (R20, R133, R2) reviewed for background checks in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure initial and weekly wound assessments were completed and failed to put interventions in place to address a resident's refusal of care and a resident's scratching behavior for 2 of 3 residents (R18, R17) reviewed for skin condition in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician ordered dressing was in place for 1 of 4 residents (R133) reviewed for pressure ulcers in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling catheter was changed as ordered and failed to keep it off the floor for 1 of 2 residents (R133) reviewed for catheters in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was being administered as ordered for 1 of 1 resident (R6) reviewed for oxygen services in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's medication was not left at the bedside for 1 of 1 resident (R18) reviewed for medications in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to ensure information regarding immunization status was in the residents electronic or paper charting for 2 of 5 residents (R17, R23) reviewed for immunizations in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent the worsening of pressure ulcers, failed to perform weekly assessments and measurements of a pressure wound, and failed to perform scheduled dressing changes for a pressure ulcer for 1 of 3 residents (R1) reviewed for pressure ulcers. These failures resulted in the deterioration and increase in size of R1's pressure ulcer from a stage 3 to unstageable.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a catheter was maintained per physician orders, failed to ensure orders were in place for a resident with a catheter, and failed to provide catheter care for 2 of 3 residents (R1 and R4) reviewed for indwelling catheters. This failure resulted in R1 being diagnosed with a urinary tract infection on 1/16/24.

Inspectors wroteBased on interview and record review the facility neglected to ensure a resident (R1) was assessed and provided pain management in a timely manner after being dropped from a mechanical lift on 11/21/23 at 5:30 AM which resulted in a right hip fracture. The facility neglected to notify the physician in a timely manner and provide ongoing nursing assessments, pain assessments, and pain management from the time of the incident on 11/21/23 at 5:30 AM through 11/22/23 at 1:25 AM (approximately 20 hours) when R1 was transported to the emergency department for evaluation and treatment of a right hip fracture. These failures resulted R1 being placed on bedrest without necessary care and effective pain management services being provided. [...]

Inspectors wroteI. Based on interview and record review the facility failed to ensure a resident (R1) was safely transferred with a mechanical lift device. This failure resulted in R1 sustaining a hip fracture on 11/21/23 at 5:30 AM during a mechanical lift transfer after the lift device tipped over with R1 in the sling on the device. R1 required medical evaluation and treatment at the hospital on [DATE] due to a right hip fracture that was sustained when the mechanical lift tipped over. This applies to one of three residents (R1) reviewed for safety in the sample of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/21/23 at 5:30 AM when facility staff dropped R1 in a mechanical lift resulting in a fracture to her right hip. The facility was notified of the Immediate Jeopardy on 12/7/23 at 11:23 AM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have a full time Administrator at the facility which contributed to deficient practices in the facility. This failure resulted in residents not receiving necessary care and services including nursing assessments, pain assessments, and pain documentation. The facility failed to follow their own policies and procedures and failed to ensure staff were trained upon hire and annually on the use of facility equipment. This has the potential to affect all 31 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to ensure a resident was assessed after a fall and had ongoing assessments for 72 hours after a fall. The facility failed to assess a resident, provide care and ongoing assessments for a resident with complaints of a cough for a week. This applies to two of three residents (R2 & R3) reviewed for quality of care in the sample of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a deaf resident with a mode of meaningful communication for 1 of 6 residents (R1) reviewed for quality of life in the sample of 6. This failure resulted in R1 being unable to communicate with his friends in the deaf community, as well as his Care Services Coordinator. R1 was unable to receive counseling services for several months and showed signs of depression and isolation.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide medically necessary social services to a deaf resident with a history of schizoaffective disorder for 1 of 6 residents (R1) reviewed for medically necessary social services in the sample of 6. This failure resulted in R1 becoming depressed, lonely, and isolated.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide feeding assistance in a dignified manner for 1 of 6 residents (R6) reviewed for resident rights in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's right to participate and develop a resident centered care plan for 1 of 6 residents (R1) reviewed for care plans in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident with clean sheets for 1 of 6 residents (R3) reviewed for clean, comfortable, and homelike in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their fall policies and procedures for a resident with a history of falls and failed to safely transfer a resident with a history of falls for 2 of 6 residents (R1, R3) reviewed for falls in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was allowed a choice of changing rooms in the facility for 4 of 4 residents (R1, R4, R5, R7) reviewed for room changes in the sample of 11.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure enough staff were on duty to assist residents for 1 of 3 residents (R2) reviewed for staffing in the sample of 11.

Inspectors wroteBased on observation, interview and record review the facility failed to document when a pain medication was given, and failed to ensure a pain medication was given as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of 11.