Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sandwich Living & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, neuromuscular bladder dysfunction, a chronic indwelling urinary catheter, and a history of UTIs did not receive catheter care in accordance with facility policy and orders. During observed care, a CNA cleaned stool from the resident’s buttocks and then, without hand hygiene, glove change, or fresh water, used the same basins to cleanse the catheter tubing from the urethra downward. The DON later confirmed that staff are expected to change gloves, water, and equipment when stool is present, consistent with the facility’s catheter care policy, but this was not followed during the observed episode.
A resident with multiple health conditions and moderate cognitive impairment fell in the dining room after tripping on puckered laminate flooring and a sticky substance along floor seams. The unsafe floor condition, which included lifted seams and floor glue, had been reported by residents and observed by staff for at least a month without adequate repair, despite facility policy requiring prompt attention to hazards.
The facility did not maintain the dining room floor in a safe condition, resulting in puckered laminate seams, sticky glue patches, and exposed nails that created tripping hazards. Multiple ambulatory residents and staff reported incidents of tripping or getting caught on the floor, and at least one resident witnessed a fall. The Maintenance Director and staff acknowledged ongoing issues with the floor installation and repeated, unsuccessful attempts to repair it.
The facility failed to identify and manage a resident's heel wound, which developed into a deep tissue injury, and did not conduct required weekly wound assessments for another resident with a stage 4 pressure ulcer. Despite physician orders and facility policies mandating regular assessments, the facility did not update care plans or document interventions, increasing the risk of infection and delayed healing.
A resident with a history of cerebral infarction, Parkinson's disease, and dysphagia experienced a 7.98% weight loss over one month due to the facility's failure to implement dietary recommendations and monitor weight as ordered. Despite being provided with a pureed meal and nutritional supplements, the resident did not receive necessary assistance or cueing during meals, and there was a lack of documentation and follow-up on dietary interventions.
Two residents experienced discomfort during breakfast due to cold air entering the dining room when a resident opened patio doors to fill bird feeders. Staff did not intervene to close the doors, and the RN was busy with medication distribution. The Administrator was unaware of the situation and expressed concerns about safety and staff inaction.
The facility failed to safely transfer a resident requiring a mechanical lift, as CNAs were unaware of the updated transfer requirement due to an outdated electronic medical record. Additionally, a resident using smoking tobacco was not reassessed for smoking safety as per facility policy, indicating a lapse in adherence to safety protocols.
A resident with an indwelling catheter was observed with the drainage bag resting on the floor, and the tube uncovered and touching the floor. CNAs and the DON confirmed that the bag should not be on the floor due to infection risks and should be in a dignity bag.
A resident with multiple sclerosis and neuromuscular dysfunction of the bladder was discharged from the ER with an order for cefpodoxime to start immediately. The facility delayed inputting the order and administering the medication until the following day. The DON confirmed the importance of timely antibiotic administration, especially given the resident's susceptibility to sepsis. No documentation was found of pharmacy or physician notification regarding the delay.
A medication error rate of 8% was identified when an RN failed to administer pantoprazole and polyethylene glycol as ordered to a resident with alcoholic hepatitis and cirrhosis. The facility's policy requires verification of medication administration records against physician orders, which was not followed.
A facility failed to use the current EHR for medication administration, resulting in errors. An RN used an outdated MAR due to lack of training on the new system, leading to missed medications for residents. Despite the presence of an LPN to assist with the new EHR, the RN continued using the old system, causing discrepancies between the MAR and physician orders.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control. A resident with a stage 4 pressure injury and catheter, another with an indwelling catheter, and a third with a heel wound did not have EBP signage or PPE available. Staff were unaware of the need for EBP, and the Director of Nursing was not informed of the requirements, resulting in a lack of appropriate precautions.
A resident with a history of verbal aggression was punched by another resident with dementia, following ongoing antagonistic behavior. Despite staff awareness of the conflict, the facility failed to prevent the altercation, resulting in physical abuse.
A resident with severe cognitive impairment experienced significant weight fluctuations and a change in Lasix dosage without the Healthcare Power of Attorney (HPOA) being notified. The facility's staff failed to communicate these changes, despite policy requirements for prompt notification of significant changes in a resident's condition.
A resident's new wound on the right shin was not assessed or reported to the physician in a timely manner. The wound, first observed by the resident's HPOA, was not documented or treated according to the facility's policy. The DON confirmed that an assessment should have been conducted upon initial identification, but this was delayed by three days.
The facility failed to perform weekly pressure wound assessments for two residents, as required by their policy. The DON stated that assessments should occur weekly, alternating between the wound care physician and the evening shift nurse. However, assessments were missing for a resident with a stage III pressure injury and another with an open heel wound. The facility lacked electronic reminders, relying on signs at the nurses' station, leading to incomplete documentation.
A facility failed to prevent residents from smoking inside and did not adequately supervise residents at risk for elopement. One resident, with a history of substance abuse, was found smoking inside despite the policy. Another resident with dementia frequently left the facility unattended, and a third resident with cognitive impairment also managed to elope. The facility's reliance on door alarms and lack of staff to monitor residents contributed to these deficiencies.
Two residents were involved in a physical altercation in their shared room, resulting in one resident sustaining a bloody nose and bruising. The incident occurred after one resident pulled back the privacy curtain, leading to a brief argument and physical confrontation. The facility's administrator confirmed the altercation, and the police were involved, with one resident receiving a citation. The facility's Abuse Prevention Program Policy was not effectively upheld, as the altercation was not prevented.
A resident with wounds did not receive prescribed Flagyl 500 mg for wound care as ordered by the physician. The DON was unaware of the order, and the MDS nurse found the missed order after the wound doctor mentioned it. Facility policy mandates that medications be administered as prescribed, which was not followed in this instance.
A facility failed to document a resident's change of condition and death. The resident, under hospice care, was unresponsive with periods of apnea and mottling. Despite these observations, no nursing assessments were documented on the day of death, including the time of death or body release details. The LPN admitted to forgetting to document due to an overwhelming day, and the DON confirmed that documentation should have been completed.
The facility failed to document a change in condition for a resident with multiple diagnoses, leading to an ER transfer without proper assessment records. Another resident with alcoholic cirrhosis and ascites did not have daily weights documented as ordered, and there was no care plan for monitoring his condition. The facility lacked a policy for daily weights, resulting in inconsistent monitoring.
A resident with dysphagia was not provided with the prescribed mechanical soft diet, leading to a choking incident. Despite a physician's order, the resident continued to receive a regular diet, resulting in a choking episode that required emergency intervention. The facility's lack of communication and adherence to dietary policies contributed to this deficiency.
The facility did not ensure menus were reviewed by a Registered Dietitian, impacting all 28 residents. The Dietary Manager rewrote menus without dietitian review due to time constraints after cooler issues and a health department inspection. The menus lacked serving sizes and recipes, and attempts to contact the dietitian were unsuccessful. Facility policy requires dietitian involvement in menu development and substitutions, which was not followed.
The facility failed to store food safely due to malfunctioning refrigeration units, with the walk-in cooler and freezer reaching unsafe temperatures. The Dietary Manager reported the cooler had been down for weeks, and domestic refrigerators were used temporarily, lacking proper thermometers. The County Health Department intervened, requiring food disposal and temporary meal solutions.
The facility failed to investigate an alleged drug diversion involving missing Norco tablets, affecting five residents on Schedule II narcotics. Despite staff reporting the missing narcotic card to the Regional Director, no investigation was conducted, contrary to the facility's abuse prevention policy. The Director of Nursing acknowledged the need for investigation, but no allegations were recorded, and the Regional Director denied awareness of the issue.
The facility failed to maintain accurate reconciliation and documentation of controlled substances, impacting six residents. Instances included missing witness signatures for wasted medications, excess dispensing of doses, and overlapping documentation. Interviews revealed non-adherence to policies, with staff expressing discomfort in discussing these issues, leading to a significant deficiency in pharmaceutical services.
The facility failed to maintain a safe environment due to a long-standing roof leak affecting the South shower room and a resident room. Observations showed debris and moldy conditions, with staff confirming the issue has persisted for years despite multiple repair bids. The facility's policy stresses the importance of a safe environment, yet the problem remains unresolved.
A long-term care facility failed to prevent the diversion of Schedule II medication for two residents. Discrepancies in medication records and forged signatures indicated that a nurse may have diverted Hydrocodone/Acetaminophen. Staff interviews confirmed that some signatures were not authentic, and the Director of Nursing admitted to not checking for overlapping documentation. The facility's policy states residents have the right to be free from misappropriation, but inadequate monitoring led to medication diversion.
Improper Catheter Care Technique Leading to Contamination Risk
Penalty
Summary
The deficiency involves failure to provide catheter care in a manner that prevented contamination for a resident with an indwelling urinary catheter and a history of urinary tract infections. The resident had diagnoses including dementia and neuromuscular dysfunction of the bladder, and physician orders and the active care plan required catheter care every shift and after each incontinent episode. Facility records showed the resident had UTIs requiring antibiotic treatment on two recent occasions. During observation, two CNAs provided care using a basin of soapy water and a basin of plain water, with one intended for washing and the other for rinsing. While providing care, one CNA cleaned stool from the resident’s buttocks using a washcloth, then, without washing her hands or changing gloves or water, obtained a new washcloth, dipped it into the same basin, and cleansed the urinary catheter tubing from the urethra downward. This sequence of actions occurred despite the resident’s chronic indwelling catheter and history of UTIs. The DON stated that when stool is present during catheter care, CNAs are expected to change gloves and water after cleaning the stool and before performing catheter care to prevent contamination of the catheter tubing. The facility’s catheter care policy also states that to prevent contamination when feces are present, staff should wash hands, change gloves, and use new equipment for catheter care.
Unsafe Dining Room Flooring Creates Fall Hazard
Penalty
Summary
A deficiency was identified when the facility failed to maintain a safe walking environment for a resident at risk for falls. Observations revealed that the dining room floor had two visible seams running its length, with areas where the laminate flooring was puckering and lifting from the surface, creating a tripping hazard. Additionally, a brown, sticky substance, identified as floor glue mixed with debris, and tiny nails were present along the seams. Residents and staff reported that the floor had been in this condition for at least a month, and complaints had been made about the hazard, but the flooring had not been replaced or adequately repaired. One resident, who was cognitively intact, reported witnessing another resident fall due to the floor condition and expressed concern about the risk posed by the puckered flooring and sticky substance. Another resident, who had moderate cognitive impairment and multiple diagnoses including dementia, anxiety, diabetes, and reduced mobility, described a fall in the dining room where his foot got stuck on the sticky floor, causing him to trip and fall face-first, resulting in a bloody nose and bruising. This resident required hospital evaluation but did not sustain fractures. The resident's care plan had previously identified him as a fall risk, and after the incident, interventions included maintaining a safe environment. Interviews with facility staff, including the Maintenance Director, DON, and RN, confirmed ongoing issues with the dining room floor seams, with staff acknowledging that residents' walkers and wheelchairs sometimes got caught on the seams. The Maintenance Director stated that attempts had been made to repair the floor with glue and nails, but the problem persisted. The Administrator acknowledged awareness of the hazard and agreed that the condition of the floor could pose a problem for resident safety. Facility policy required malfunctioning equipment or hazards to be immediately addressed, but the unsafe floor condition remained unresolved at the time of the survey.
Unsafe Dining Room Flooring Creates Tripping Hazards for Ambulatory Residents
Penalty
Summary
The facility failed to maintain the dining room floor in a safe and functional condition for nine ambulatory residents. Observations revealed two visible seams running the length of the dining room laminate flooring, with random patches of a brown, sticky substance (identified as floor glue mixed with debris) and tiny nails along both sides of the seams. The laminate flooring was puckering at various points, causing the edges to lift from the surface and creating a tripping hazard. The surveyor confirmed that the puckered areas caught her foot, and the sticky substance posed an additional fall risk. Dining room tables were placed throughout the area, increasing the likelihood of residents encountering these hazards. Interviews with residents and staff confirmed ongoing issues with the floor. One resident reported witnessing another resident fall due to the floor condition and stated that her chair legs often got caught in the puckered areas. Another resident described tripping on the sticky floor while assisting another resident, attributing the incident to the glue applied to keep the floor down. The Maintenance Director acknowledged that the laminate was installed over existing vinyl against his advice, and that he had attempted to address the recurring seam issues by nailing or gluing them down. Staff also reported that the floor was poorly installed and that both residents and staff had experienced tripping or catching their feet on the seams. Facility records indicated that the floor had been problematic for at least a month, with multiple complaints from residents.
Failure to Conduct Regular Wound Assessments and Implement Interventions
Penalty
Summary
The facility failed to identify and properly manage a wound on a resident's right heel, which developed into a deep tissue injury (DTI). The resident, who had a history of peripheral vascular disease and was at moderate risk for pressure ulcer development, had a medical boot that caused a sore on her foot. Despite physician orders to monitor the area for complications, the facility did not conduct weekly wound assessments or update the care plan to include interventions for the wound. The wound was not assessed after its initial identification, and the care plan lacked focus areas or interventions related to the wound. Another resident with multiple sclerosis and a stage 4 pressure ulcer on the buttock also did not receive the required weekly wound assessments. The facility's wound assessment policy mandates weekly assessments for all wounds, but the last documented assessment for this resident was several weeks prior to the survey. This lack of regular assessment and documentation is contrary to the facility's policy and leaves the resident's condition inadequately monitored. The facility's failure to adhere to its own policies regarding wound assessment and care resulted in inadequate monitoring and management of pressure ulcers for both residents. This oversight increased the risk of infection and delayed wound healing, as the facility did not ensure that appropriate interventions were in place or that the wounds were regularly assessed and documented.
Failure to Prevent Significant Weight Loss in Resident
Penalty
Summary
The facility failed to prevent a significant unplanned weight loss for a resident, identified as R8, who experienced a 7.98% weight loss over one month. R8 had a medical history that included cerebral infarction, Parkinson's disease, depression, vomiting without nausea, and dysphagia. Observations revealed that R8 was not consuming meals, as evidenced by an untouched lunch meal despite being seated with a pureed texture meal and a nutritional supplement. Staff members approached R8 during the meal but did not offer assistance or cueing. R8's care plan included dietary recommendations such as pudding, magic cup, mighty shake, benecalorie, and medpass, but there was no documentation of follow-up or administration of these recommendations, except for medpass and pudding. The facility's records showed a lack of adherence to the physician's order for weekly weights, with a two-week delay before the first weight was recorded. Interviews with staff, including a registered nurse and a registered dietitian, highlighted the importance of timely weight monitoring and implementation of dietary recommendations. The dietitian confirmed that R8's weight loss was significant and that the dietary recommendations should have been followed up on quickly. The facility's Unintended Weight Loss policy required monthly or weekly weights and physician notification of significant weight loss, but these protocols were not adequately followed, contributing to the deficiency.
Failure to Maintain Comfortable Dining Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike dining experience for two residents, R21 and R7, due to cold air entering the dining room. On the morning of December 4, 2024, R21 and R7 were observed eating breakfast near sliding glass doors leading to the patio. Another resident, R5, opened the doors to fill bird feeders, allowing cold air to blow into the dining room. R21 expressed discomfort due to the cold and left his meal unfinished, while R7 also left the dining room with food still on his plate. Several staff members noticed the cold but did not intervene to close the doors. The weather was in the 20s with wind, exacerbating the cold conditions inside. R5 stated he fills the bird feeders independently and was not instructed by staff to keep the doors closed. The Registered Nurse, V6, was preoccupied with medication distribution and did not notice the residents leaving the dining room. The Administrator, V1, was unaware of R5's actions and expressed concerns about his safety and the staff's lack of intervention. The facility's policy emphasizes the residents' right to a safe and comfortable environment, which was not upheld in this instance.
Deficiencies in Resident Transfer and Smoking Safety Assessment
Penalty
Summary
The facility failed to ensure a resident was transferred safely, as evidenced by the improper handling of a resident with specific transfer requirements. The resident, diagnosed with conditions such as cerebral infarction and Parkinson's disease, was noted to require a mechanical lift for transfers due to full staff dependence. However, during an observation, two CNAs transferred the resident from bed to wheelchair without using a mechanical lift or a gait belt, contrary to the physician's order. The CNAs were unaware of the updated transfer requirement, as the electronic medical record banner did not reflect the need for a mechanical lift, indicating a lapse in communication and record updating. Additionally, the facility did not adequately assess a resident for safe smoking practices. The resident, who uses smoking tobacco, had not been reassessed for smoking safety since May, despite the facility's policy requiring quarterly assessments. The resident was observed with an unlit cigar and mentioned smoking outside at night. The social services staff confirmed that the resident should have undergone a quarterly safety assessment, highlighting a failure to adhere to the facility's smoking safety policy.
Failure to Maintain Catheter Bag Properly
Penalty
Summary
The facility failed to maintain an indwelling catheter drainage bag in a manner that prevents contamination for one resident. The resident, who was admitted with multiple diagnoses including multiple sclerosis, flaccid neuropathic bladder, acute kidney failure, and a history of urinary tract infections (UTIs), was observed with a catheter drainage bag resting on the floor. This observation was made on two separate occasions, and the drainage tube was also noted to be uncovered and touching the floor. Certified Nursing Assistants acknowledged that catheter drainage bags should not be on the floor due to infection risks and should be placed in a dignity bag. The Director of Nursing confirmed that the catheter drainage bag should not be on the floor and that the drainage tube should be covered and closed.
Failure to Timely Administer Antibiotic
Penalty
Summary
The facility failed to initiate an antibiotic as ordered for a resident reviewed for pharmacy services. The resident, who was admitted with multiple diagnoses including multiple sclerosis and neuromuscular dysfunction of the bladder, was seen in the emergency room for a fever and abdominal pain. He was given IV antibiotics and discharged with an order for cefpodoxime 200 mg twice daily for 10 days, starting on the same day. However, the facility did not input the order until the early hours of the following day, and the medication was not started until then. The Director of Nursing acknowledged that the medication should have been started the same day it was ordered, especially since the resident is very susceptible to going septic when ill. The facility's policy requires the charge nurse to notify the pharmacy if a drug is unavailable, but there was no documentation of any notification to the pharmacy or physician regarding the delay in administering the antibiotic.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 8%, which exceeds the acceptable threshold of 5%. During a medication pass observation, a registered nurse (RN) did not administer pantoprazole 40 mg and polyethylene glycol 17 grams to a resident as per the physician's orders. The resident, who was admitted with alcoholic hepatitis, alcoholic cirrhosis, and esophageal varices, was supposed to receive these medications at 8:00 AM, but they were neither given nor offered. The facility's policy requires that the medication administration record be verified against physician orders, which was not adhered to in this instance. The Director of Nursing and a Nurse Consultant confirmed that medications should be administered as ordered by the physician.
Failure to Use Current EHR Leads to Medication Errors
Penalty
Summary
The facility failed to utilize the current electronic health records (EHR) medication administration record (MAR) for administering medications to residents, leading to medication errors. On December 3, 2024, the facility transitioned to a new EHR system. However, on December 4, 2024, a registered nurse (RN) was observed administering medications to three residents using the outdated EHR's MAR. The RN admitted to not being trained on the new system and continued using the old system despite the presence of a licensed practical nurse (LPN) who was there to assist with the new EHR. This resulted in the RN administering medications based on potentially outdated information. The failure to use the current EHR led to specific medication errors. For instance, a resident did not receive pantoprazole and polyethylene glycol as prescribed, as these medications were not listed on the old MAR used by the RN. The current EHR's MAR and the physician's order sheet (POS) indicated these medications should have been administered. Similarly, another resident's medications, divalproex and levothyroxine, were not listed on the old MAR but were current on the new EHR's MAR and POS. This discrepancy highlights the facility's failure to ensure staff were adequately trained and using the correct system for medication administration, as per the facility's updated policy from September 2023.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control practices. Resident R19, who had a stage 4 pressure injury and an indwelling urinary catheter, did not have a sign indicating EBP on his door, nor was personal protective equipment (PPE) readily available. Certified Nursing Assistants (CNAs) V11 and V12 entered R19's room without donning gowns, and V12 handled the urinary drainage bag without gloves. Despite R19's care plan indicating the need for EBP due to his wounds and catheter, the staff was unaware of the requirement, and no isolation measures were in place. Similarly, Resident R4, who had an indwelling urinary catheter and was at risk for urinary tract infections, did not have EBP signage or PPE near his room. The Director of Nursing (V3) was unaware that residents with catheters required EBP, leading to a lack of appropriate precautions. Additionally, Resident R11, who had a wound on her heel and required assistance with transfers and toileting hygiene, did not have EBP signage or PPE available until after CNAs V11 and V12 had already provided care. The facility's policy required EBP for residents with devices like urinary catheters and skin openings, but this was not consistently implemented, resulting in a failure to adhere to infection control protocols.
Resident Conflict Leads to Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident, R1, from physical abuse, resulting in R1 being punched in the face by another resident, R2. R1, who has a history of paranoid thoughts and verbal aggression, was observed with a bruise on his face and reported being punched by R2. R1's care plan indicated a history of verbal aggression and potential for self-injury, with behaviors such as waving arms and stomping feet when angry. R1 was known to antagonize R2, including yelling and making inappropriate gestures. R2, who has dementia and a history of criminal behavior, was involved in an altercation with R1. On the day of the incident, R2 was outside with a CNA when R1 began yelling and making gestures at him. Despite attempts by the CNA to redirect R2, he became angry and struck R1. R2's care plan noted potential for verbal and physical aggression, and staff were aware of the ongoing conflict between R1 and R2. The facility's abuse investigation confirmed that R2 struck R1, and staff interviews revealed that R1 had been antagonizing R2 for some time. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and outlines measures to prevent such occurrences. However, the facility failed to effectively manage the conflict between R1 and R2, leading to the physical altercation.
Failure to Notify HPOA of Medication and Weight Changes
Penalty
Summary
The facility failed to notify a resident's Healthcare Power of Attorney (HPOA) regarding significant changes in medication and weight, which is a requirement for maintaining informed decision-making about the resident's health care. The resident in question, identified as R4, was admitted with diagnoses including dementia with behaviors, seizures, and depression. The resident's records showed a change in Lasix dosage from 40 mg to 80 mg, and significant weight fluctuations, with a 6.4 percent weight loss followed by an 11.4 percent weight gain over a few months. However, there was no documentation of re-weights or notifications to the HPOA regarding these changes. Interviews with the HPOA and facility staff confirmed the lack of communication. The HPOA was not informed about the weight changes or the increase in Lasix dosage, learning about the weight loss from a hospice nurse weeks later. A registered nurse admitted to not notifying the HPOA about the medication change, and the Director of Nursing acknowledged that the HPOA should have been informed about both the weight changes and the medication adjustment. The facility's policy requires prompt notification of significant changes in a resident's condition, including a 5 percent weight gain or loss in 30 days, which was not adhered to in this case.
Failure to Assess and Notify Physician of New Wound
Penalty
Summary
The facility failed to assess and notify the physician of a new wound on a resident's right shin, which was first observed by the resident's Healthcare Power of Attorney (HPOA) on a visit. The HPOA, who is a nurse, discovered a 1.5-inch round wound with a white/yellow slough wound bed and yellow drainage, covered by a gauze dressing. Despite the wound being present since at least the Friday before the HPOA's visit, there were no treatment orders for the wound, and the physician had not been notified. The Registered Nurse (RN) who was informed of the wound did not perform an initial assessment or notify the physician, as required by the facility's policy. On a subsequent visit, another RN removed the dressing and confirmed the presence of the wound, which had not been properly assessed or documented until three days after it was first observed by the HPOA. The Director of Nursing (DON) confirmed that an assessment should have been conducted upon the initial identification of the wound, even if it initially appeared as a blister. The facility's Skin Condition Monitoring policy mandates that any skin abnormality should be assessed, documented, and have a specific treatment order, which was not followed in this case.
Failure to Perform Weekly Pressure Wound Assessments
Penalty
Summary
The facility failed to perform weekly assessments for pressure wounds for two residents, R5 and R6, as required by their Decubitus Care/Pressure Areas policy. The Director of Nursing (V2) stated that the wound care physician assesses wounds every other Friday, and the opposite week, the evening shift nurse is responsible for completing the assessments. However, for R5, the facility was unable to locate the wound assessment for 9/13/24, despite the presence of a stage III pressure injury on her right shin that had not resolved. V2 acknowledged the absence of electronic charting reminders and relied on signs at the nurses' station to remind staff to complete assessments, which were not documented in the residents' electronic charting. Similarly, for R6, the facility could not produce a wound care physician note for 9/6/24 or a facility assessment from 9/13/24. R6 had an open pressure injury on his right heel. V2 admitted that the assessments were not completed and emphasized their importance for ensuring correct treatments and tracking wound progression. The facility's policy mandates documentation of pressure areas upon identification and at least once each week, which was not adhered to in these cases.
Inadequate Supervision and Smoking Policy Enforcement
Penalty
Summary
The facility failed to prevent residents from smoking within the premises and did not adequately supervise residents at risk for elopement. Resident 1, who has a history of psychoactive substance abuse and unsteadiness on feet, was observed with cigarettes and a vaping device in his room, contrary to the facility's smoking policy. Despite being educated on the smoking policy, Resident 1 continued to smoke both cigarettes and marijuana inside and outside the facility. Staff reported that the administrator instructed them to overlook such behaviors, and there was a lack of enforcement of the smoking policy. Resident 2, diagnosed with dementia and severe cognitive impairment, exhibited frequent exit-seeking behaviors. Despite being identified as high risk for wandering, Resident 2 repeatedly left the facility unattended, reaching as far as the parking lot and the street. The facility's interventions, such as door alarms, were insufficient to prevent these incidents, and staff reported being unable to constantly monitor the resident due to staffing limitations. Resident 3, with moderate cognitive impairment, also managed to elope from the facility. On one occasion, the resident was found outside after triggering a door alarm and was difficult to redirect back inside. The facility did not employ additional measures such as wander guards, relying solely on responding to door alarms, which proved inadequate in preventing the resident from leaving the premises.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by an incident involving two residents, R1 and R2. According to the facility's incident report, R1 claimed that R2 pulled back the privacy curtain in their shared room and, following a brief argument, struck him in the face. Conversely, R2 stated that after pulling back the curtain, R1 struck him twice in the face before he retaliated by hitting R1 once. There were no eyewitnesses to the altercation. Observations noted R1 with a small yellow/purple bruise on the left side of his nose and under his right eye, while R2 reported being hit on both sides of his jaw. The facility's administrator confirmed that both residents were involved in a physical altercation, with R1 sustaining a bloody nose. The police were called, and both residents declined hospital visits. The following day, R1 decided to press charges against R2, resulting in R2 receiving a citation. The facility's Abuse Prevention Program Policy emphasizes the commitment to protecting residents from abuse by anyone, including other residents. However, the incident indicates a failure to uphold this policy, as the altercation between R1 and R2 was not prevented.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident's physician orders were followed, specifically for a resident with wounds who was prescribed Flagyl 500 mg to be crushed and applied to each wound bed twice daily with every dressing change. On August 5, 2024, the resident was observed in the dining room, and during an interview, he mentioned having wounds that the wound doctor examines. A progress note from July 29, 2024, indicated that orders were received from the primary care physician to follow the wound care recommendations made on July 19, 2024. However, the Director of Nursing (V2) was unaware of the order, and the Minimum Data Set nurse (V3) discovered the missed order only after the wound doctor brought it to her attention. The facility's policy requires that all medications be given as prescribed by the physician and at the designated time, which was not adhered to in this case.
Failure to Document Change of Condition and Death
Penalty
Summary
The facility failed to document a change of condition and death for a resident who was under hospice care. The resident was admitted to the facility and later to hospice, receiving morphine and Ativan as ordered. On the day of the resident's death, nursing progress notes indicated that the resident was unresponsive, with periods of apnea, no urine output, and mottling of the skin. Despite these observations, there were no nursing assessments documented for the day of death, including the time of death or details about the release of the body. The hospice nurse assessed the resident earlier in the day, noting a decline in condition, but the facility's LPN did not document these changes or the notifications made to the family and physician. The LPN admitted to forgetting to document due to an overwhelming day. The Director of Nursing confirmed that the agency nurse had access to the electronic record and should have documented the resident's condition changes, notifications, and time of death, as per the facility's policy.
Failure to Document Change in Condition and Monitor Daily Weights
Penalty
Summary
The facility failed to properly assess and document a change in condition for a resident (R1) and did not obtain daily weights as ordered for another resident (R2). R1 was admitted with multiple diagnoses, including sepsis and cognitive communication deficit. On a specific date, R1 was sent to the emergency room due to a change in condition, but the nurse (V2) did not document any assessments, vital signs, or reasons for the transfer. R1's guardian was informed of the transfer but was not provided with detailed information about R1's condition. The nurse acknowledged the importance of documenting assessments to provide a clear picture of the resident's condition. For R2, who was admitted with alcoholic cirrhosis of the liver and ascites, there was an order for daily weights to monitor fluid retention. However, weights were not documented for two consecutive days, and there was no care plan for monitoring R2's condition. The facility lacked a policy for daily weights, and the staff did not consistently follow the order for daily weight monitoring. R2 reported discomfort due to fluid retention and went to the emergency room for a paracentesis, highlighting the importance of monitoring his condition.
Failure to Provide Altered Diet Leads to Choking Incident
Penalty
Summary
The facility failed to provide an altered diet for a resident with dysphagia, leading to a choking incident. The resident, who had a history of oropharyngeal phase dysphagia and other medical conditions, was supposed to be on a mechanical soft diet as per a physician's order dated April 26, 2024. However, the resident continued to receive a regular diet, which resulted in a choking episode on June 16, 2024, requiring the Heimlich Maneuver and abdominal thrusts to dislodge the food. The resident's care plan and dietary assessments were not updated to reflect the necessary dietary changes, and there was a lack of communication between the nursing and dietary staff. The dietary manager indicated that diet changes are made only when a paper order is received from the nurse, and there was no tracking system for when dietary cards were updated. The resident was served a regular diet despite the order for a mechanical soft diet, and the dietary manager was unaware of when the dietary card was changed. Interviews with staff revealed that the resident was served inappropriate food, leading to the choking incident. The CNA who was feeding the resident reported that the resident was eating regular food and began choking, turning blue before the food was expelled. The facility's policies and procedures for diet orders and quarterly assessments were not followed, contributing to the failure to provide the appropriate diet for the resident.
Removal Plan
- In house audit of all diet orders to ensure accurate reconciled with dietary cards.
- IDT will review Speech Therapy recommendations daily in morning meeting.
- Regional Director in-serviced Dietary Supervisor on quarterly and annual dietary assessments.
- Staff in-serviced on appropriate diets by Regional Director and Administrator.
- Compliance will be monitored through the QA process.
- Speech orders will be reviewed daily during morning meeting by the IDT.
- DON/Designee will ensure all new diet orders are communicated to dietary.
- DON/Designee will in-service on diet orders once a month.
Failure to Review Menus by Dietitian
Penalty
Summary
The facility failed to ensure that menus were reviewed by a Registered Dietitian, affecting all 28 residents. The Dietary Manager, identified as V12, admitted to rewriting the facility's dining menus without having them reviewed by the Registered Dietitian due to time constraints, following issues with the cooler and an inspection by the County Health Department. The handwritten menus provided by V12, covering the period from June 19th through June 30th, lacked serving sizes and recipes. Attempts to contact the Registered Dietitian, identified as V30, were unsuccessful. The facility's policy requires the Dietitian to assist in menu development and sign off on all menu substitutions, which was not adhered to in this instance.
Improper Food Storage Due to Malfunctioning Refrigeration
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as evidenced by the malfunctioning of the walk-in cooler and freezer. The County Health Department documented that during an onsite visit, the walk-in cooler was at 55 degrees and the freezer at 73 degrees, leading to the disposal of all food stored in these units. The Dietary Manager, V12, confirmed that the cooler had been down for 6-7 weeks and that the freezer was also failing, with temperatures recorded as high as 80 degrees. Despite these issues, food was still stored in the malfunctioning freezer for several days before being discarded. The facility resorted to using domestic refrigerators, which were not equipped to handle the cooling needs of a commercial kitchen. These units lacked proper thermometers, and the County Sanitarian noted that they were only a temporary solution. The facility's policy required frozen foods to be at 0 degrees or lower and refrigerated foods at 41 degrees or lower, which was not adhered to. The Dietary Manager also reported being short-staffed, which may have contributed to the oversight in addressing the refrigeration issues promptly.
Failure to Investigate Alleged Drug Diversion
Penalty
Summary
The facility failed to investigate an allegation of drug diversion involving missing narcotic medication, specifically Norco tablets, which are Schedule II narcotics. This issue affected five residents who were on Schedule II narcotics during the time of the alleged incident. The report indicates that a missing narcotic card was reported by two staff members, V18 and V8, to V19, the Regional Director of Clinical Operations, over the phone. However, V19 allegedly dismissed the report and did not initiate an investigation. The staff members involved could not recall which resident's medication was missing due to the time elapsed since the incident. The facility's policy on abuse prevention requires immediate reporting and investigation of discrepancies in controlled substance inventories. Despite this policy, the report highlights that the administration did not investigate the missing narcotic card. The Director of Nursing, V2, acknowledged the importance of investigating such allegations to prevent ongoing theft. However, the report notes that no allegations of misappropriation were recorded for the relevant months, and V19 denied any awareness of the drug diversion allegations.
Deficiency in Controlled Substance Reconciliation and Documentation
Penalty
Summary
The facility failed to maintain accurate reconciliation and documentation of controlled substances, impacting six residents. The report highlights multiple instances where controlled substances, such as Hydrocodone/Acetaminophen and Morphine, were not properly accounted for, with discrepancies in count sheets and missing witness signatures for wasted medications. For instance, one resident had 41 tablets of Norco wasted without a second nurse's signature, contrary to the facility's policy requiring two nurses to witness and document the destruction of controlled substances. The report also details specific cases where medications were dispensed in excess of the prescribed amounts or without proper documentation. One resident's count sheets showed overlapping and duplicate documentation, while another resident's sheets indicated more doses were dispensed than ordered. Additionally, there were instances where medications were documented as dropped or wasted without a second nurse's cosignature, raising concerns about potential diversion of narcotics. Interviews with staff, including the Director of Nursing and Licensed Practical Nurses, revealed a lack of adherence to established policies and procedures for handling controlled substances. The facility's pharmacist noted numerous instances of undocumented waste and expressed concerns about the discomfort and unease among nursing staff when discussing these issues. Despite these observations, the facility failed to identify and address the discrepancies, leading to a significant deficiency in pharmaceutical services.
Facility Fails to Address Long-Standing Roof Leak, Compromising Safety
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents, as evidenced by the condition of the South shower room and a resident room that was taken out of service. Observations revealed insulation and debris from the ceiling on the floor and hanging from the ceiling in the South shower room, with an area measuring approximately 10-12 feet by 3-4 feet directly above the shower. Additionally, a resident room not in service had a section of the ceiling that had fallen, with peeling wallpaper and apparent mildew or mold around the top of the wall. Interviews with staff, including the Maintenance Director, indicated that there has been an ongoing leak in the South shower room and another area of the facility for the last three years, with multiple bids submitted to fix the roof issue, but no action taken by corporate. The Maintenance Director reported that the roof is made of fabric layers, and a leak at one of the seams worsens with heavy rain. Despite submitting multiple bids for repairs over the past three years, the issue remains unresolved. Staff members, including CNAs, confirmed the long-standing nature of the problem, describing the ceiling as moldy, cracked, and sagging. The facility's policy emphasizes the importance of maintaining a safe and clean environment, yet the ongoing issues with the roof and ceiling have not been addressed, leading to unsafe conditions for residents and staff.
Medication Diversion in LTC Facility
Penalty
Summary
The facility failed to prevent the diversion of Schedule II medication, specifically Hydrocodone/Acetaminophen, for two residents. For one resident, discrepancies were found in the Medication Administration Record (MAR) and Controlled Substance Proof of Use records, indicating that more tablets were dispensed than should have been administered. The records showed overlapping dates and forged signatures, suggesting that a nurse may have diverted the medication. Interviews with staff revealed that some signatures on the count sheets were not authentic, and the Director of Nursing (DON) admitted to not checking for overlapping documentation, which allowed the issue to go undetected. For the second resident, similar issues were identified with the administration of Hydrocodone/Acetaminophen. The MAR and count sheets showed duplicate administrations and inconsistencies in signatures, indicating that the medication was likely diverted by a nurse. The Regional Director of Clinical Operations noted that the signatures and handwriting on the count sheets appeared to be from the same person, further supporting the suspicion of medication diversion. The facility's Abuse Prevention Program policy states that residents have the right to be free from misappropriation of their property, including medications. However, the facility's failure to properly monitor and document the administration of controlled substances led to the misappropriation of medications for both residents. The lack of oversight and verification of count sheets allowed the diversion to occur without detection.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 237 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sandwich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion On Main Street, The | 0.7 mi | ★★★★★ | 17 | 0 |
| Hillside Rehab & Care Center | 8.3 mi | ★★★★★ | 9 | 0 |
| Pearl At The Tillers | 13.8 mi | ★★★★★ | 2 | 0 |
| Pearl Of Orchard Valley | 14.4 mi | ★★★★★ | 7 | 2 |
| Prairie Crossing Lvg & Rehab | 15.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.