Sandwich Living & Rehab Center

In the surveyor’s words

From the most serious findings on record at Sandwich Living & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 5, 2026

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

• Immediate jeopardy, isolatedF805Jul 3, 2024

  Based on observation, interview, and record review the facility failed to provide an altered diet for a resident with dysphagia for 1 of 3 residents (R6) reviewed for therapeutic diets in the sample of 22. This failure resulted in R6 experiencing a choking episode requiring the Heimlich Maneuver and abdominal thrusts to dislodge. The Immediate Jeopardy began on 4/26/24 when an order was received to downgrade R6's diet from regular consistency to a mechanical soft consistency and R6 continued to be served a regular diet. V18 (Registered Nurse) was notified of the Immediate Jeopardy on 6/28/24 at 11:10 AM. […]

• Immediate jeopardy, isolatedF600Dec 8, 2023

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

• Immediate jeopardy, isolatedF689Dec 8, 2023

  I. Based on interview and record review the facility failed to ensure a resident (R1) was safely transferred with a mechanical lift device. This failure resulted in R1 sustaining a hip fracture on 11/21/23 at 5:30 AM during a mechanical lift transfer after the lift device tipped over with R1 in the sling on the device. R1 required medical evaluation and treatment at the hospital on 11/22/23 due to a right hip fracture that was sustained when the mechanical lift tipped over. This applies to one of three residents (R1) reviewed for safety in the sample of five. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/21/23 at 5:30 AM when facility staff dropped R1 in a mechanical lift resulting in a fracture to her right hip. […]

• Actual harm, isolatedF686Dec 5, 2024

  Based on observation, interview, and record review the facility failed to identify a wound prior to becoming a deep tissue injury (DTI), failed to ensure pressure ulcer interventions were in place, and failed to ensure weekly wound assessments were done for 2 of 5 residents (R11, R19) reviewed for pressure ulcers in the sample of 13. These failures resulted in R11 being at an increased risk of infection and delayed wound healing. The findings include: 1. R11's face sheet printed on 12/4/24 showed an admitted [DATE] and diagnoses including but not limited to fracture of right lower leg, urinary tract infection, pneumonia, and peripheral vascular disease. […]