Inspection·August 5, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review the facility failed to ensure resident's were free from physical abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. Residents Affected - Few The findings include: The facility's Incident Report dated 7/24/24 shows R1 claims that he was on his side of the room and that R2 pulled back the curtain and following a brief argument that R2 struck him in the face. R2 claims that he pulled back the curtain and following a brief argument, R1 struck him twice in the face before he struck R1 once. There were no eyewitnesses. On 8/5/24 at 9:43 AM, R2 was in his room sitting at the bedside eating breakfast. R2 said he used to have a room mate but he got moved. R2 said R1 was watching dirty movies and making noise and he asked him to stop. R2 said it embarrassed him and he could hear what was going on. R2 said R1 and him argued and he opened up R1's privacy curtain. R2 said R1 put up a fist like he was going to hit and he told him don't touch my face. R2 said R1 then hit him on one side of the jaw and went on about how he was a cop in New York. R2 said he told R1 are you happy?, You hit my face, don't hit my face! and then R1 punched him in the other side of the jaw. R2 said he then punched R1 one time in the nose and R1 started screaming. On 8/5/24 at 11:45 AM, R1 was in his room watching TV with the volume loud. R1 had a small yellow/purple resolving bruise on the left side of his nose and under his right eye. R1 said his old room mate punched him in the nose. R1 said he was in his room with the curtain closed having privacy and R2 opened up the curtain and punched him in the nose. R1 said there was no argument and R1 did not punch R2 at all. R1 said he had one drop of blood coming from his nose but no other injuries. R1 said the next day he saw the bruising to his nose and decided to press charges against R2. On 8/5/24 at 10:37 AM, V1 Administrator said R1 and R2 were room mates. V1 said R1 was on his side of the room masturbating to porn and R2 could hear him and asked him to stop. V2 said R2 claims R1 hit him twice in the face and R2 hit R1 once. V1 said the stories matched perfectly up until who hit who. V1 said there were no witnesses and both were separated by staff. V1 said R1 had a bloody nose, but there were no other injuries. V1 said the police were called and both declined going to the hospital. V1 said the next day R1 called the police back and wanted to press charges against R2. V1 said the police gave R2 a citation and he has to go to court. R1's Progress Notes dated 7/24/24 shows resident was in a physical fight with another resident around 3:00 PM today. Resident was noted to have a minor nosebleed. (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 3 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 08/05/2024 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)