A list of the most recent deficiencies for Sandwich Rehab and Hcc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-02 | 2024-04-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-02 | 2024-04-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-02 | 2024-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-02 | 2024-02-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-02 | 2024-02-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-02 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-02 | 2024-02-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-02 | 2024-02-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-25 | 2024-02-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-25 | 2024-02-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-25 | 2024-02-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-25 | 2024-02-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-19 | 2024-02-13 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-01-19 | 2024-02-13 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-02 | 2024-02-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-02 | 2024-02-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-08 | 2024-01-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-08 | 2024-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-08 | 2024-01-03 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-08 | 2024-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-12-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-06 | 2023-10-10 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-10-06 | 2023-10-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-06 | 2023-10-10 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-10-06 | 2023-10-10 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-06 | 2023-10-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-14 | 2023-10-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-14 | 2023-10-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-14 | 2023-10-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-27 | 2023-08-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-27 | 2023-08-15 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-06-27 | 2023-07-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-27 | 2023-07-21 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-27 | 2023-07-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-27 | 2023-07-21 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-22 | 2023-06-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-04-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-17 | 2023-03-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-08 | 2023-03-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-08 | 2023-03-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-08 | 2023-02-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-08 | 2023-02-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-08 | 2023-02-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-08 | 2023-02-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-08 | 2023-02-25 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-02-08 | 2023-02-25 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-02-08 | 2023-02-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-08 | 2023-02-25 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-08 | 2023-02-25 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-02-08 | 2023-02-25 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-02-08 | 2023-02-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-02-08 | 2023-02-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-08 | 2023-02-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-18 | 2022-12-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-28 | 2022-05-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-28 | 2022-05-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-28 | 2022-05-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-28 | 2022-05-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-28 | 2022-05-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-28 | 2022-05-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-28 | 2022-05-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-28 | 2022-05-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-28 | 2022-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-20 | 2022-01-01 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-02 | 2021-12-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-20 | 2021-07-26 | Y |
