Inspection·April 18, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe walking environment for a resident at risk for falls for 1 of 3 residents (R3) reviewed for falls in the sample of 11. The findings include: On 4/16/25 at 12:07 PM, R4 was sitting on her bed. R4 said she usually goes to the dining room for meals, but was feeling a little irritated today. R4 said she usually sits in a table closer to the sliding, glass door. R4 said the floor is messed up in the dining room and she saw a male resident fall about a month ago because of it. R4 stated, The floor is coming up in some places and the leg of her chair gets caught up in it. I've told everyone about it because I don't want anyone to get hurt. R4 said the facility told her that the floor was going to be replaced, but nothing has happened and it's been a month. R4's facility assessment dated [DATE] showed she was cognitively intact. On 4/16/25 at 12:09 PM, the surveyor toured the dining room area. The room has a small half wall at one end and a sliding, glass door at the opposite end. There were 2 visible seams in the laminate flooring that ran the length of this room. Along the visible seams there were random patches of a brown, sticky substance (floor glue combined with floor debris) and tiny nails that were run along both sides of the seams in other areas. Both seam lines had various areas where the laminate flooring was puckering (each side of the seam was lifted from the surface and posed a fall risk hazard). The surveyor touched these areas with her shoe. The puckered areas caught the surveyor's foot and could pose a tripping hazard. The brown substance along the seams was thick and sticky (also posing a potential fall risk hazard).The two seams run the length of the dining room and the dining room tables are placed sporadically around the dining room. On 4/16/25 at 1:26 PM, R3 was lying in bed. R3 said had fallen in the dining room a while ago. R3 said he used his walker to go to the dining room and stopped at his table. R3 said another female resident asked for his help and he left his walker parked to get her a clothing protector. R3 said when he turned around to take the clothing protector to her, his foot got stuck on the floor and he tripped. R3 said the floor was really sticky and it made me trip. R3 said the facility put the floor glue down because the floor comes up along that line (the seam in the laminate flooring). R3 said he fell face first and got a bloody nose. R3 said he went to the hospital, but was lucky not to break anything. R3 said he thought they fixed the floor after he fell. R3 said he shouldn't have parked his walker and tried to walk without it, but the floor was what tripped him up. R3 said his nose and under his right eye was pretty bruised up, but it's better now. R3 said he couldn't remember if any staff members were in the dining room, but he saw V10 (Registered Nurse - RN) right after he fell. (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 5 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 04/18/2025 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)