Health inspection·July 10, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and document a residents change of condition and failed to obtain daily weights as ordered for 2 of 3 residents (R1, R2) reviewed for nursing care and assessments in the sample of 3. Residents Affected - Few The findings include: 1. R1's admission record shows he was admitted to the facility 3/16/23 with multiple diagnoses including sepsis, cognitive communication deficit, dysphagia, and aphasia. On 7/10/24 at 12:15 PM, R1 was observed sitting up in his wheelchair at the dining room table. He was dressed and well groomed. He did not verbally respond to any questions. Staff were assisting him with his meal. R1's progress notes for 7/4/24 at 6:47 PM show V2 (RN/DON - Registered Nurse/Director of Nursing) received a physician order to send R1 to the ER (emergency room). The note does not include any assessment, vital signs or reason for the transfer. No previous notes or assessments were documented for 7/4/24. On 7/10/24 at 10:00 AM, V3 (R1's guardian) said V2 (RN/DON) called her on 7/4/24 to tell her R1 was being sent out to the ER, but could only tell her it was because his breathing was really bad. She had no vital signs to report to her. V2 said as a nurse herself, she would have expected V2 to give her details of some assessment and vital signs or what his oxygen saturation levels were at the time. On 7/10/24 at 10:38 AM, V2 (RN/DON) said on 7/4/24 she sent R1 out to the hospital due to a change in his condition. His respirations and blood pressure were both elevated. She said his oxygen saturation was 95%, but at one point it was down to 88% and applied oxygen. She could not recall what time this occurred, and did not document it in the record. V2 said R1's lungs sounded terrible. She said during the day she was monitoring R1 and assessing his vital signs and it should have been documented. V2 said it is important to document everything to paint a picture of the resident and their condition. On 7/10/24 at 12:40 PM, V4 (RN) said if a resident is having a change of condition the nurse should get vital signs including oxygen saturation level, a blood sugar to see if they are high or low, lung sounds, and an overall assessment. All of this information should be documented in the progress notes to cover yourself and show what you did, and it paints a picture for the next person so they know what happened. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146133 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146133 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandwich Living & Rehab Center 902 East Arnold Street Sandwich, IL 60548 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)