Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Sandy River Center during CMS and state inspections, most recent first.
Failure to follow ordered daily weights for a resident with CHF. The resident had a physician order for daily weights with provider notification parameters for weight gain, but the TAR showed no evidence the weights were completed for several days, and the weight summary indicated daily weights were not started until later. The Market Clinical Lead reviewed the record and confirmed the missed weights.
A resident with epilepsy and an order for phenobarbital BID missed multiple doses because the medication was not available when needed. MARs and nursing notes showed doses were missed due to delayed pharmacy delivery, lack of an active script, and the facility running out of stock in Pyxis/controlled substance supply, with the DON and Market Clinical Lead confirming the missed and late doses.
Care plans were not updated to reflect the current needs of two residents. One resident had swallowing issues, was edentulous, and had physician orders for upright positioning during and after meals plus education about aspiration and choking, but the care plan did not address those needs. Another resident had been receiving PT for over 2 months after a change in weight-bearing status, but the care plan did not include the current PT services. The DON, Director of Rehab, and ULM confirmed the omissions.
Housekeeping and maintenance services were not adequately provided across multiple units, the laundry room, and a common area. Surveyors observed fruit flies in a conference room, heavily soiled dining room floors, dirt and debris in a linen closet, black buildup in shower rooms, missing or damaged privacy curtains, chipped paint, linens on the laundry room floor, exposed insulation from cut sheetrock, missing linoleum, flies in a resident room, broken or rusted baseboard heaters, torn fall mats, dirty bathrooms, cracked tiles, dusty fans and air filters, patched but unpainted walls, and other uncleanable or damaged surfaces. Facility leadership confirmed the findings.
Kitchen sanitation, food storage, and dish machine monitoring failures were observed. A surveyor found residue on food disposal and the stove hood, a rusty mouse trap, food and trash on the floor, flies in the kitchen, and dusty ceiling vents, tiles, and grid. Food items in the walk-in freezer and refrigerator were not properly labeled, dated, or secured, expired items were found in unit refrigerators, and a meal tray with uncovered bowls was left in a refrigerator. Dish machine logs were incomplete and showed wash and rinse temperatures below required levels, and the chef and administrator confirmed the findings.
Unsecured Laundry Room Exposed Chemicals: A surveyor found the laundry room door not fully closed and latched, with multiple cleaning chemicals left in the open and no one present in the room. The Administrator confirmed that confused residents who ambulate or use wheelchairs could access the chemicals when the door was not secured.
A resident ordered to receive continuous O2 at 2 L/min via NC was observed in the dining room after breakfast with the oxygen tubing coiled on the table and not connected to an oxygen source. The resident stated that oxygen was supposed to be worn all the time, and the surveyor confirmed the issue with an RN, who then went to find portable oxygen.
The facility failed to complete 2 annual performance evaluations for a CNA employed for more than 1 year. During record review and interview, the Administrator stated she could not find any performance evaluations for the CNA.
Nurse Staffing Information Not Visible to Residents The facility failed to post the daily nurse staffing information in an area visible to residents. Surveyors observed the staffing list only in the foyer between locked doors or upstairs, where residents would need a passcode to access the elevator. An LPN and the Administrator confirmed the posting was not available downstairs and was not visible to residents.
The facility failed to provide sufficient staffing to meet residents' needs, resulting in delayed care and increased falls. Interviews with residents and staff revealed that only two CNAs were available for an entire floor, causing delays in basic care and response to call bells. A CNA and RN confirmed staffing shortages, leading to preventable falls and delayed care. The DON acknowledged that the facility did not staff to acuity levels, and a review showed numerous falls across shifts.
The facility failed to provide written information to several residents or their representatives about their rights to accept or refuse medical treatment and to formulate an advance directive. A review of clinical records for seven residents showed no evidence of this information being provided, and the Market Clinical Advisor confirmed the lack of documentation.
The facility failed to maintain a sanitary and comfortable environment across all units, common areas, and the laundry room. Observations revealed soiled floors, dirty caulking, chipped paint, dust accumulation, and stained ceiling tiles in various units. Additionally, the patio fence door was broken, and the laundry room had a heavy lint build-up. These issues were confirmed by facility staff during interviews.
The facility did not ensure that three residents with mental health diagnoses, whose stays extended beyond 30 days, were referred for PASRR Level II evaluations. Initially admitted for short-term convalescence, these residents continued to reside in the facility without the necessary evaluations being conducted, as confirmed by the Market Clinical Advisor.
The facility failed to update and implement care plans for residents with specific medical needs, leading to deficiencies in their care. A resident with obstructive sleep apnea and COPD had a broken CPAP machine for over a month without an updated care plan. Another resident with COPD and CHF received continuous oxygen therapy without a corresponding care plan. Additionally, a resident with PTSD had no documented efforts to address their triggers. These deficiencies were confirmed by staff and surveyors.
The facility failed to ensure timely review and revision of care plans by the IDT within 7 days after comprehensive assessments for several residents. Additionally, a resident's care plan was not updated to address significant weight loss and nutritional needs, despite a noted weight loss since admission.
The facility failed to provide adequate respiratory care for a resident with severe morbid obesity, COPD, and sleep apnea by not replacing a broken CPAP machine for over a month. Additionally, another resident's oxygen tubing was not changed weekly as required, with inaccurate documentation of care. These deficiencies indicate a failure to adhere to professional standards of practice in respiratory care.
The facility failed to provide adequate snacks for residents outside of scheduled meal times across six units. Observations and interviews revealed limited snack options, such as white bread and a few crackers, with residents and staff confirming the lack of variety and availability. The Food Service Director acknowledged the issue, citing staff absences as a contributing factor.
The facility was found to have multiple deficiencies in kitchen sanitation and food storage. Observations included soiled ceiling vents, lights, and tiles, chipped paint on the hood system, and food equipment with dried particles. Unlabeled and undated food items were found in storage areas, and a cook was observed without facial hair protection. These issues were confirmed by the Food Service Director and the cook.
The facility failed to maintain a sanitary garbage storage area, with trash bags observed in open containers outside the building over four consecutive days. The Administrator and Maintenance Director confirmed these findings during the survey.
The facility failed to maintain complete and accurate clinical records for residents. One resident's ADLs documentation was incomplete over 11 days, lacking records for essential care activities. Another resident's oxygen tubing management was inaccurately documented, with tubing not changed as per active orders. The DON and Market Clinical Advisor confirmed these deficiencies.
The facility did not ensure the Infection Preventionist attended the required quarterly QAPI/QAA meetings, missing 3 out of 4 meetings. The facility's policy mandates the presence of the Infection Preventionist or a designee, but no alternate was designated. The Administrator and DON confirmed the absence, although reports were provided for review.
The facility failed to secure a medication cart, leaving it unlocked and unattended, and did not remove expired medications from storage. Additionally, vaccines were improperly stored in a dormitory-style refrigerator, which poses a risk of freezing. These deficiencies were confirmed by staff during the survey.
The facility failed to ensure a safe environment by not addressing a hazard at the nursing station. A surveyor observed that the laminate wall covering was chipped and missing pieces, creating sharp edges accessible to residents, staff, and visitors. The Market Clinical Advisor confirmed this hazard during an interview.
A facility failed to document monitoring of side effects for psychotropic medications prescribed to a resident with anxiety and depression. The resident was on multiple medications, including Abilify, Buspirone, Trazodone, and Sertraline, but the clinical record lacked evidence of side effect monitoring. This deficiency was confirmed by the DON during a surveyor interview.
A CNA-M failed to sanitize her hands between administering medications to two residents. After discarding a medication cup, she bypassed a hand sanitizer station and began preparing medications for another resident without sanitizing her hands. When questioned, she acknowledged the oversight.
The facility failed to maintain cleanliness and repair in its dining areas and kitchenettes, as observed by surveyors. Refrigerators, microwaves, and dining tables in several units were found soiled with dried liquids and food debris. Additionally, kitchenette cabinet doors had chipped paint, creating uncleanable surfaces. These deficiencies were confirmed with the Administrator.
The facility was found deficient in properly storing, labeling, and dating food items in various unit refrigerators and the kitchen. Observations included unlabeled, expired, or moldy food items accessible to residents, and cleanliness issues in the walk-in freezer. These deficiencies were confirmed by the Food Service Director and the Administrator.
Failure to Follow Ordered Daily Weights for CHF
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including congestive heart failure received treatment and care in accordance with physician orders by not completing ordered daily weights. The resident had an order for daily weights with instructions to notify the provider if there was a weight gain greater than 2 lbs in 1 day or 5 lbs in a week for CHF. Review of the October Treatment Administration Record showed no evidence that daily weights were completed on 10/18/25, 10/19/25, 10/20/25, or 10/21/25, and the weight summary in the clinical record showed that daily weights were not started until 10/21/25. During an interview on 11/25/25, the Market Clinical Lead reviewed the clinical record and confirmed that daily weights were not done for those dates.
Failure to Maintain Availability of Ordered Seizure Medication
Penalty
Summary
The facility failed to maintain adequate pharmaceutical services to ensure that physician-ordered phenobarbital was available and administered to a resident with epilepsy. The resident had an order for Phenobarbital 64.8 mg, 1 tablet by mouth twice daily for seizures, with doses scheduled for 8:00 a.m. and 8:00 p.m. The October 2025 MAR showed three consecutive missed doses: the 8:00 p.m. dose on 10/16/25 and both the 8:00 a.m. and 8:00 p.m. doses on 10/17/25. Nursing progress notes documented that the resident was a new admission and the medication was awaiting pharmacy delivery, and that the medication was not available in Pyxis. A provider note stated the pharmacy contacted the facility after 6:00 p.m. requesting a prescription because no current script was available for dispensing, and an urgent prescription was issued for immediate dispensing. The same resident also missed a scheduled 8:00 p.m. phenobarbital dose on 11/2/25 and did not receive the 8:00 a.m. dose on 11/3/25 until 2:26 p.m. The November MAR notes stated that the pharmacy would send the medication the next day and that the medication was not available. Review of the controlled substance book showed the facility had no remaining doses on hand after the morning dose on 11/2/25 and did not receive a refill until 11/3/25 at 2:08 p.m. During interviews, the DON confirmed the missed doses, and the Market Clinical Lead stated the nurse should have notified the provider by 10/31/25 that a script was needed before the medication ran out.
Care Plans Not Updated for Current Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect residents’ current needs for 2 of 39 care plans reviewed. For one resident, the clinical record showed the resident was edentulous and at risk for choking with swallowing issues, and physician orders directed the resident to be fully upright for meals, remain upright for 45 minutes after meals, and receive education about the risks of aspiration, choking, and death if eating foods not on the food list. However, the care plan did not address the risk of aspiration or choking, and it did not include the ordered interventions for upright positioning or education. For another resident, the record showed the resident began receiving PT services after a change in weight-bearing status, but the care plan did not include a care area or intervention for the resident’s current PT services. The DON, Director of Rehab, and Upper Level Unit Manager confirmed these findings during interviews.
Housekeeping and Maintenance Failures Across Multiple Units
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across multiple units, the laundry room, and a common area. Surveyors observed small fruit flies around and on a table in the main office conference room, heavily soiled dining room floors on the Rangeley and [NAME] Units, dirt and debris in a linen closet, black buildup on shower room grout, missing hooks and disrepair in privacy curtains for resident rooms 502, 503, and 506, chipped and missing paint on unit entrance doors, linens on the laundry room floor, and an approximately one foot by one foot section of sheetrock cut out of a wall exposing insulation. A common area floor in front of the [NAME] Unit entrance doors also had an approximately two inch by four inch section of linoleum missing, creating an uncleanable surface. During additional tours, surveyors found numerous house flies in a Porter Unit resident room, baseboard heater covers with chipped or missing paint, a torn fall mat exposing foam, a broken baseboard heater cover, heavily soiled bathrooms with dirt around toilets, cracked or broken floor tiles, a window shade on the floor, broken wardrobe drawers, and bedpans on the floor. Other observations included rusted and chipped baseboard heaters, dusty fans and air filters, a dirty floor with a sticky substance, a patched and peeling wall that was not painted, a dusty nightstand, caked dirt in a shower threshold, missing sheetrock and crumbling putty patches behind toilets, gaps around toilet floor tiles filled with dirt, a wall gouge behind a bed, a bathroom light switch that did not work, holes in drywall that were patched but not painted, and a cove base by a toilet that was not attached to the wall. The District Manager for Healthcare Services, Director of Operations, Manager of Housekeeping and Laundry, and the Administrator confirmed the findings.
Kitchen sanitation, food storage, and dish machine monitoring failures
Penalty
Summary
The kitchen was not maintained in a clean and sanitary manner. During a kitchen tour, a surveyor observed dried liquid residue on the food disposal and stove hood, a rusty mouse trap on the floor under the dish machine, food, trash, and equipment on the floor under and around equipment and shelving, and a large number of house flies flying around the kitchen and landing on vents, lights, and tables. The outside kitchen door next to the freezer door was propped open without a screen door, and the ceiling air vents, ceiling tiles, and ceiling grid over food preparation areas were dusty and dirty. The emergency food storage room also had ceiling tiles with large brown stains. Food storage practices were also not followed in the walk-in freezer, walk-in refrigerator, and unit refrigerators. In the walk-in freezer, a package of fish patties was not labeled, a case of previously opened sausage patties was not secured and was open to the air, and a case of beef sandwich slices had a large buildup of ice on the box. In the walk-in refrigerator, a package of meatballs was not dated and labeled, and two packages of whipped topping did not have a thaw date even though the manufacturer’s instructions stated the product was only good for 14 days after thawing. On the unit, an opened gallon of milk was found past its expiration date, beef snack sticks were expired, a container of cantaloupe was soft and watery with a date on the lid, and a meal tray with two bowls was left uncovered in the refrigerator. The dish machine logs for June through September were also incomplete, with missing entries and rinse temperatures documented below the required level, and staff and the administrator confirmed these findings.
Unsecured Laundry Room Exposed Chemicals
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards related to chemical storage when the laundry room door was observed not fully closed and latched. On 9/15/25 at 8:15 p.m., a surveyor entered the laundry room and found no one present while multiple chemicals were sitting in the open, including a 20-ounce container of Simple foaming Coil Cleaner, a 32-ounce bottle of Bio Enzymatic Odor Eliminator, a 32-ounce bottle of Rapid Multi-surface Disinfectant Cleaner, two 1 pound 13-ounce containers of Germicidal Disposable wipes, and two 1 pound 10-ounce containers of Bleach Germicidal wipes. A sign on the door stated, “Please Make Sure The Door Is Shut When You Leave. Thank You!!” The surveyor reviewed Safety Data Sheets for the chemicals found in the room, which listed first aid measures for inhalation, skin contact, eye contact, and ingestion. During an interview at 8:25 p.m., the Administrator confirmed the finding. The Administrator stated that the lower level has confused residents who ambulate and confused residents who move around the facility in wheelchairs, and that with the laundry room door not secured, they would have access to these chemicals.
Failure to Provide Ordered Continuous Oxygen
Penalty
Summary
The facility failed to follow a physician order for continuous oxygen for one resident who was reviewed for oxygen use. During an observation in the dining room, the resident was sitting at the table after breakfast with oxygen tubing coiled on the table next to the resident, but the tubing was not attached to an oxygen source. When asked, the resident stated that he or she was supposed to wear oxygen all the time. A review of the resident’s physician order dated 8/8/25 showed oxygen at 2 liters per minute via nasal cannula continuously. The surveyor confirmed the finding with RN #1, who then went to find portable oxygen for the resident.
Missing Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to complete 2 annual performance evaluations that were due to be completed at least every 12 months for Certified Nursing Assistant #1, who had been employed since 2/21/23. During review of performance evaluation records, the surveyor requested the annual evaluations due in 2024 and 2025, but the Administrator stated during an interview on 9/18/2025 at 1:38 p.m. that she was unable to find any performance evaluations for CNA1.
Nurse Staffing Information Not Posted Where Residents Could See It
Penalty
Summary
The facility failed to post the nurse staffing information in an area visible to residents for 3 of 4 days of survey. On 9/15/25 at 8:20 p.m., a surveyor observed the staff listing with census in the foyer between the entrance and exit doors, but the doors were locked to exit the building to the foyer area, so residents could not see it without assistance. During an interview on 9/15/25 at 8:23 p.m., LPN #2 stated the only posted nurse staffing information she was aware of was upstairs, where residents would have to use an elevator that required a passcode to operate. On 9/16/25 at 2:10 p.m. and 9/17/25 at 4:00 p.m., the surveyor again observed the staff listing with census in the foyer area, not viewable to residents unless they were able to leave the building. On 9/17/25 at 4:05 p.m., the Administrator stated the Daily Nurse Staffing Form was only posted in the foyer between the entrance and exit doors, confirmed there was no posting downstairs, and confirmed residents could not use the elevator without entering a passcode. The surveyor confirmed the nurse staffing information was not posted in an area visible to residents at that time.
Inadequate Staffing Leads to Delayed Care and Increased Falls
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents, particularly those requiring assistance with Activities of Daily Living (ADLs). Interviews with residents revealed that there were only two Certified Nursing Assistants (CNAs) on duty to cover an entire floor during both day and evening shifts, leading to delays in providing basic care such as offering a basin of water or assisting with brushing teeth. One resident reported waiting over two hours to be changed after being incontinent, and another resident mentioned that call bells were not answered in a timely manner, a concern that had been repeatedly raised in resident council meetings. Staff interviews corroborated these issues, with a CNA and a Registered Nurse (RN) both indicating that staffing shortages were a persistent problem, resulting in preventable falls and delayed care. The RN noted that there were many residents requiring two-person assistance, which further strained the limited staff resources. The Director of Nursing confirmed that the facility did not staff to acuity levels and acknowledged that falls occurred on days when staffing was insufficient. A review of the fall report over three months showed a significant number of falls across all shifts, highlighting the impact of inadequate staffing on resident safety.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. This deficiency was identified for seven residents during a review of their clinical records. Specifically, the records for these residents lacked evidence that the facility had provided or attempted to provide this crucial information. The residents involved were admitted to the facility on various dates, but none had documentation indicating they were informed of their rights concerning medical treatment decisions or advance directives. Interviews with the Market Clinical Advisor confirmed the absence of documentation in the clinical records of these residents. The advisor acknowledged that the records did not show that the residents or their representatives were asked about or offered assistance with completing an advance directive. This oversight affected residents who were admitted over a range of dates, indicating a systemic issue in the facility's process for informing residents of their rights upon admission.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment across all six units, common areas, a patio, and the laundry room. During a tour, it was observed that the upper level common area had a public bathroom with a dirty floor and caulking around the toilet. In the Mt. [NAME] Unit, multiple resident rooms had soiled floors, dirty caulking around toilets, and chipped or missing paint on cabinet doors. The Mt. Blue Unit's dining room floor was heavily soiled, and several resident rooms had chipped paint, dust accumulation, and stained ceiling tiles. In the Sugarloaf Unit, ceiling tiles in the hallway were stained, and several resident rooms had dirty caulking around toilets and missing towel bars. The Porter Unit had chipped paint on kitchenette cabinets and dusty dining room floors. The Rangeley Unit's shower room had a commode bucket on the floor, and resident rooms had chipped paint and exposed sheetrock. The [NAME] Unit had a resident room with chipped paint and exposed sheetrock in the bathroom. The lower level common area had stained ceiling tiles, and the laundry room had a heavy build-up of lint on and behind the dryers and washers. Additionally, the patio fence door between the Rangeley Unit and the [NAME] Unit was broken and missing two door panels, with a green chair blocking the opening. These findings were confirmed by the Maintenance Director, the Regional Health Care Services Housekeeping Supervisor, and the Administrator during interviews conducted on the same day as the observations.
Failure to Conduct PASRR Level II Evaluations for Long-Term Residents
Penalty
Summary
The facility failed to ensure that three residents with specialized mental health diagnoses, whose stays extended beyond the expected 30 days, were referred to the appropriate state-designated authority for a PASRR Level II evaluation and determination. Each resident was initially admitted under a short-term convalescence admission, which did not require further PASRR evaluation according to their PASRR Level I determination letters. However, when their stays transitioned from short-term to long-term, the facility did not forward the PASRR Level I to the State Mental Health Authority to assess the need for a PASRR Level II evaluation. Resident #48, diagnosed with Bipolar Disorder, Resident #66, diagnosed with Anxiety, and Resident #68, also diagnosed with Bipolar Disorder, all continued to reside in the facility beyond their short-term stays and were assessed to require Nursing Facility level of care. Despite this change in their stay status, there was no evidence in their clinical records to indicate that the necessary PASRR Level II evaluations were pursued. The Market Clinical Advisor confirmed these findings during an interview.
Deficiencies in Care Plan Updates and Implementations
Penalty
Summary
The facility failed to update and implement care plans for residents with specific medical needs, leading to deficiencies in their care. Resident #28, who has obstructive sleep apnea, morbid obesity, and COPD, had a care plan that was not updated to reflect the broken CPAP machine, which had been out of service for over a month. Despite the resident's request for oxygen as a temporary measure, the care plan did not reflect this change in respiratory care. This oversight was confirmed during an interview with the unit manager and a surveyor. Similarly, Resident #69, diagnosed with COPD and CHF, received continuous oxygen therapy from May to July 2024, yet their care plan lacked any focus, goals, or interventions related to oxygen therapy. This deficiency was confirmed by a surveyor in an interview with the Market Clinical Advisor. Additionally, Resident #26, who has PTSD, depression, and anxiety, had a care plan that did not document any efforts to identify or address PTSD triggers, as confirmed by the Director of Nursing. These failures indicate a lack of proper care plan updates and implementations for residents with specific health needs.
Failure to Timely Review and Revise Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were reviewed and revised by the interdisciplinary team (IDT) within 7 days after each comprehensive assessment. This deficiency was identified for four residents whose IDT meetings were not held within the required timeframe following their Minimum Data Set (MDS) assessments. Specifically, Resident #7's IDT meeting occurred 30 days after the MDS date, while Residents #32, #33, and #65 had their IDT meetings before their MDS dates, indicating a lack of timely review and revision of care plans. Additionally, the facility did not revise a resident's care plan to address significant weight loss and nutritional needs. Resident #42, who was admitted with a dysphagia advanced texture diet, experienced a weight loss of 10.3 lbs. since admission. Despite this, the care plan was not updated to include appropriate nutritional interventions, and there was no evidence of follow-up monthly weight monitoring. The Registered Dietitian and Market Clinical Advisor confirmed that the care plan had not been revised to address the resident's nutritional needs.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for Resident #28, who was admitted with severe morbid obesity, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea requiring a CPAP machine. Despite having active orders for CPAP use and maintenance, the Treatment Administration Record (TAR) showed that these orders were not completed for 24 days. The resident's CPAP machine was reported as broken, and there was a lack of evidence that the facility made adequate attempts to contact the CPAP supplier or follow up on the issue. Interviews revealed that the resident had been without a CPAP machine for over a month, and the facility had not taken necessary actions to replace it or arrange for a sleep study. Additionally, the facility failed to change the oxygen tubing for Resident #69 as per the procedure, which requires replacement every seven days. Observations showed that the tubing had not been changed since 6/18/24, despite active orders indicating weekly changes. The Treatment Administration Record (TAR) inaccurately documented that the tubing was changed on several dates, which was confirmed to be incorrect by a surveyor. These deficiencies highlight the facility's failure to adhere to professional standards of practice in providing respiratory care, as evidenced by the lack of timely equipment replacement and inaccurate documentation of care provided to the residents.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide nourishing snacks to residents who wished to eat at non-traditional times or outside of scheduled meal service times across six units. Observations and interviews revealed that the snack cupboards and refrigerators in the units were inadequately stocked, with limited options such as white bread, Ensure, a few small cracker packages, and minimal other items like small snack oatmeal pies and a small container of tuna salad. Residents reported not being offered snacks and having to rely on minimal options like toast, with no yogurt, puddings, or hydration cups available. Staff interviews confirmed the lack of variety and quantity of snacks and drinks, with reports of having to wait hours for additional supplies from the kitchen. The Food Service Director acknowledged the issue, attributing it to the absence of two staff members responsible for stocking the kitchenettes. The Food Service Director District Manager confirmed that upon his arrival, the units were not properly stocked with enough snacks or a variety of snacks for the residents. The deficiency was observed over two days of the survey, affecting all six units, and no policy or procedure for stocking snacks in the kitchenettes was provided to the surveyor.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during an initial kitchen tour. The surveyor noted several deficiencies, including heavily soiled ceiling vents, lights, and tiles in the dish room, as well as a dirty air vent at the kitchen entrance. The hood system had chipped paint, creating an uncleanable surface, and food equipment such as the slicer and mixer had dried food particles. Additionally, untreated cement blocks were found under the ice machine. In the dry storage room, several food items were unlabeled and undated, and similar issues were found in the reach-in and walk-in refrigerators and freezer. The facility's policies on food storage and environment cleanliness were not adhered to, as confirmed by the Food Service Director. Furthermore, the facility failed to ensure proper labeling and dating of food items in various storage areas, including the dry storage room, reach-in refrigerator, and walk-in refrigerator and freezer. The Activity room refrigerator also contained undated whipped cream canisters, and the temperature log for the refrigerator/freezer was incomplete. Additionally, a cook was observed not wearing facial hair protection, which was confirmed during an interview. These findings indicate a lack of compliance with the facility's policies on food storage, cleanliness, and employee hygiene, as confirmed by the Food Service Director and the cook.
Improper Garbage Storage
Penalty
Summary
The facility failed to maintain a sanitary garbage storage area, which was observed over four consecutive days. On the first day, a surveyor noted trash bags stored in an open container outside the building by a lower level exit. This observation was repeated the following day, and the Administrator confirmed the findings during an interview. On the third day, both the surveyor and the Administrator observed the same issue, with the Administrator again confirming the findings. On the final day, the surveyor and the Maintenance Director observed trash stored in an open container outside the kitchen, with the Maintenance Director confirming the observation.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for residents, as evidenced by the deficiencies found during the survey. For one resident, documentation of activities of daily living (ADLs) was incomplete over an 11-day period, with missing records for bed mobility, eating, bathing, dressing, drinks/snacks, hygiene, toileting, transfers, wheelchair mobility, and walking. The Director of Nursing confirmed the lack of documentation, noting that the resident had not received a shower or tub bath since admission, and multiple shifts were missing records of care provided. Another resident's clinical records were found to be inaccurate regarding the management of oxygen tubing. The resident's active orders required weekly changes of the oxygen tubing, with each component labeled with the date and initials. However, the tubing observed on the resident's wheelchair was dated over a month prior, and the Treatment Administration Record (TAR) did not reflect the required weekly changes. A surveyor confirmed the discrepancy with the Market Clinical Advisor, who acknowledged the need to inform staff to change the tubing again.
Infection Preventionist Absence from QAPI/QAA Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist attended the required quarterly Quality Assurance Performance Improvement/Quality Assurance Assessment (QAPI/QAA) Committee meetings. A review of the meeting attendance sheets revealed that the Infection Preventionist did not attend any of the four quarterly meetings, specifically on 10/31/23, 1/26/24, and 7/29/24. According to the facility's policy, the QAA Committee must include the Infection Preventionist or a designee, but the facility did not have an alternate designee for this role. The Administrator and Director of Nursing confirmed that the Infection Preventionist was absent from 3 of the 4 meetings in the past year, although they provided copies of reports for review at the meetings.
Medication and Vaccine Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as observed during a survey. On one occasion, a medication cart was left unlocked and unattended in the hallway of the Sugarloaf unit, allowing potential access to medications by residents and unauthorized persons. This incident was confirmed by the Unit Manager upon her return to the cart. Additionally, expired medications were found in the lower level Medication Storage room and on a medication cart in the Rangeley Lake unit. Specifically, expired bottles of Geri Care Senna liquid and Geri Care Aspirin were observed, with expiration dates indicating they should have been removed from use. Furthermore, the facility was found to be improperly storing vaccines in a dormitory-style refrigerator with a freezer, which is against the guidelines provided by the United States Centers for Disease Control and Prevention. This type of refrigerator poses a significant risk of freezing vaccines, which can compromise their efficacy. The Clinical Market Advisor confirmed the use of such a refrigerator for storing pneumococcal vaccines and Purified Protein Derivative (PPD) used for tuberculosis testing, highlighting a failure in adhering to proper vaccine storage protocols.
Accident Hazard Due to Damaged Laminate Wall Covering
Penalty
Summary
The facility failed to maintain a safe environment for residents, staff, and visitors by not addressing an accident hazard at the nursing station. On August 5, 2024, a surveyor observed that the laminate wall covering at the nursing station was chipped, gouged, and missing pieces along the bottom edge. This condition created sharp edges that posed a risk of injury to anyone passing by. The Market Clinical Advisor confirmed the presence of this hazard during an interview, acknowledging the potential danger it posed.
Lack of Monitoring for Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to document the monitoring of side effects for psychotropic medications prescribed to a resident. The resident, who was admitted with diagnoses of anxiety and depression, was on multiple medications including Abilify, Buspirone, Trazodone, and Sertraline. Despite these prescriptions, the clinical record lacked evidence of monitoring for side effects, as confirmed by the Director of Nursing during an interview with surveyors. This oversight was identified during a review of the resident's records, highlighting a deficiency in the facility's medication management practices.
Inadequate Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control procedures during a medication pass task. On August 8, 2024, at 8:34 a.m., a surveyor observed a Certified Nursing Assistant Med Technician (CNA-M) administering medications to a resident using a plastic medication cup. After discarding the cup into the trash, the CNA-M bypassed a hand sanitizer station in the resident's room and proceeded to the medication cart without sanitizing her hands. She then began preparing medications for another resident. When questioned by the surveyor, the CNA-M admitted she had not sanitized her hands and acknowledged the necessity of doing so between residents. Later, at 9:53 a.m., the surveyor discussed the observed lack of hand hygiene during the medication pass with the Market Clinical Advisor.
Facility Fails to Maintain Cleanliness in Dining Areas and Kitchenettes
Penalty
Summary
The facility failed to maintain housekeeping and maintenance services necessary to ensure a safe, clean, and homelike environment in its dining areas and kitchenettes. During a survey conducted on 4/29/24, it was observed that the refrigerator shelves and door shelves in several units, including Mount Blue, Sugarloaf, and Rangely Lake, were soiled with dried liquids. Additionally, the kitchenette cabinet doors on one unit had chipped paint, creating an uncleanable surface. Microwaves in multiple units were found with dried food debris, and the kitchenette cabinets in the Mount Blue unit were soiled with food crumbs. Dining room tables in the Rangely Lake and another unit were also observed to be soiled with food debris. These findings were confirmed with the facility's Administrator.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to properly store, label, and date food items in the walk-in refrigerator and unit refrigerators across six units, the first-floor recreation area, and the kitchen. During the survey, numerous food items were found unlabeled, expired, or out of date, which were accessible for resident use. Specific observations included a variety of food items such as cookies, muffins, dips, sauces, ice cream, and sandwiches that were either undated or past their expiration dates. Additionally, some items, like a container of brown rice, were found with visible mold. In the kitchen, the reach-in refrigerator contained undated and expired items, including ham salad and milk. The walk-in freezer was noted to have excessive dirt and debris on the floor, indicating a lack of proper maintenance and cleanliness. These findings were confirmed by the Food Service Director and the Administrator during the survey, highlighting a significant deficiency in the facility's food storage and handling practices.
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 112 citations issued within 25 miles in the last 12 months — 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 Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Park Rehab & Living Center | 3.5 mi | ★★★★★ | 18 | 0 |
| Edgewood Rehab & Living Ctr | 3.9 mi | ★★★★★ | 42 | 0 |
| Pinnacle Health & Rehab Canton | 14.8 mi | ★★★★★ | 34 | 0 |
| Maplecrest Rehab & Living Center | 18.4 mi | ★★★★★ | 0 | 0 |
| Rumford Community Home | 20.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sandy River Center.
100% money-back within 48 hours.
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.