Sandy River Center

In the surveyor’s words

From the most serious findings on record at Sandy River Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF692Jul 30, 2025

  Based on the facility reported incident, record reviews and interviews, the facility failed to provide the appropriate textured meal to Resident #1 who was identified with swallowing issues and required a dysphagia advanced texture for all meals. This failure to provide the correct texture at the supper meal on 7/24/25 resulted in the resident choking, needing transfer to the hospital and subsequently passing away for 1 of 12 residents reviewed that were requiring dysphagia advanced texture meals. This failure determined an immediate jeopardy situation existed. […]

• Actual harm, isolatedF600Apr 20, 2022

  Based on the facility reported incident dated 4/12/22, review of the facility's investigation report dated 4/18/22, facility policy, record review, and interviews, the facility failed to protect a resident from potentially emotional and physically harm and causing the resident discomfort for 1 of 3 sampled for abuse (Resident #1). A reasonable prudent person could have psychosocial harm. Findings: On 4/12/22 at 6:57 p.m., the Division of Licensing and Certification received a facility reported incident. The report stated that on 4/12/22, the facility received notice that a current employee had shared a video of a resident receiving care. The facility started an immediate investigation. […]

• No harm, potential for more than minimal, widespreadF725Aug 8, 2024

  Based on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs). Findings: During an interview on 8/5/24 10:33 a.m., Resident #181 indicated 2 Certified Nursing Assistant (CNA)'s on duty to cover entire floor - days and evening, and they are not offering a basin of water or assist to brush teeth. Resident #181 further indicated he/she asked a CNA for help the other day and she said, that figures because she was too busy. […]

• No harm, potential for more than minimal, patternF584Sep 18, 2025

  Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 6 of 6 Units (Mt. [NAME], Mt. Blue, Sugarloaf, Porter, Rangeley and [NAME]), the laundry room and a common area for 3 of 4 days of survey.(9/15/25, 9/16/25 and 9/18/25).Findings: 1. On 9/15/25 at 6:20 p.m., two surveyors observed small fruit type flies around and on the table in the main office conference room. 2. On 9/15/25 at 8:00 p.m., a surveyor observed the following findings on the Rangeley Unit: - The linen closet had linen and dirt/debris on the floor. […]

• No harm, potential for more than minimal, patternF657Sep 18, 2025

  Based on record reviews and interviews, the facility failed to ensure that care plans were updated to reflect the residents current needs for 2 of 39 resident care plans reviewed (Resident #44 [R44] and R11).Findings: 1. On 9/18/25, a review of R44's clinical record was completed. Documentation in R44's nurse note dated 6/20/25 indicated the resident is edentulous and is at risk for choking and has swallowing issues. R44's Physician orders dated 8/19/25, indicated the resident is to be fully upright for meals and to encourage R44 to remain upright for 45 minutes after meals. In addition if R44 wants to eat foods not on his food list, educate him on the possibilities of aspiration, choking and death. A review of R44's care plan was completed. […]