Sandhills Care Center

Inspectors wroteRecord review of the facility policy Hand Hygiene with a revised date of 4/1/24 revealed the following: -all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and to visitors. -hand hygiene was a general term for cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). -hand hygiene using soap and water was to be performed when hands were visibly soiled, before and after eating, after using the restroom, and any exposure to diarrhea type illnesses. -hand hygiene was indicated using ABHR when; [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(D)(i) Based on observation, record review and interview; the facility failed to ensure medications were securely stored to prevent potential unauthorized access. This had the potential to affect any resident who were mobile within the facility. The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review; the facility failed to maintain the cleaning of food storage surfaces and prepare and serve food in a manner to prevent potential food borne illness. This had the ability to affect all residents that ate from the facility kitchen. The total sample size was 18 and the facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interviews, the facility failed to notify the Primary Care Practitioner (PCP) of a change in condition for 1 (Resident 19) of 1 sampled resident. The facility staff identified a census of 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5%. The number of opportunities for administration observed was 28 with 2 errors (involving Residents 6 and 16) revealing an error rate of 7.14%. The sample size was 7 and the facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to implement and maintain hand hygiene practices, ensure the dishwasher temps were monitored, and failed to implement and maintaining the cleaning or food preparation equipment and surfaces to prevent the potential for food borne illness. This had the potential to affect all facility residents. The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to prevent potential spread of infection when staff 1) had not worn the required Personal Protective Equipment (PPE) during care of Resident 20's feeding tube (a flexible plastic tube placed into the stomach or bowel used to provide nutritional needs), 2) failed to implement hand hygiene measures during incontinence care of Resident 15 and while residents were assisted with eating during the meal service, and 3) failed to implement a legionella water management plan to prevent the potential for water-borne illness. The sample size was 17 and the facility census was 28.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility failed to protect Residents 1, 9, 15, 18 and 24's right to be free from staff-to-resident verbal abuse. The sample size was 5 and the facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review; the facility failed to administer medication with an error rate of less than 5 percent (%). This included crushing medications that should not be crushed for residents 20 and 28, giving medications outside of the recommended/schedules times for Residents 1 and 26, and not observing the consumption of the entire dose of a medication for Resident 1. The sample size was 8 and the facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(21) Based on record review and interviews, the facility failed to treat Resident 1 with dignity and respect when assisting the resident with cares. The sample size was 1 and the facility census was 28.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility failed to notify Resident 11's physician of a weight loss and Resident 24's representative of increased edema, shortness of breath, persistent cough, difficulty ambulating, and new physician orders related to the resident's change in condition. The sample size was 2 and the facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C3 Based on interview and record review; the facility failed to complete a Discharge Recapitulation Summary for Resident 29. The sample size was 1 and the facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7 Based on record review and interviews, the facility failed to identify causal factors and to develop and/or revise interventions to prevent ongoing falls for Resident 24. The sample size was 5 and the facility census was 33.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8 Based on observations, record review and interviews; the facility failed to evaluate weight loss, to develop and/or revise interventions to prevent ongoing weight loss and to ensure nutritional interventions were implemented for 2 (Residents 11 and 15) of 5 sampled residents. The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12E Based on observation, interview, and record review; the facility failed to ensure medications were always kept locked, outdated medications were not available for administration, and failed to ensure medications placed for destruction were accounted for until destroyed. The facility census was 28.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview; the facility failed to check the Nurse Aide/Med Aide Registry for 4 of 6 sampled staff for findings to protect residents from potential abuse.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report allegations of potential staff to resident abuse for 2 (Residents 1 and 2) of 3 sampled residents and to submit an investigation to the required State Agency within 5 working days. The facility census was 25.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.12B Based on record review and interview; the facility pharmacist failed to ensure emergency and immediate use medications were available. This had the potential to affect all residents in the building. The facility staff identified a census of 25.

Inspectors wroteLicense Reference Number NAC 175 12-006.11E Based on observation, record review, and interview; the facility failed to provide clean and sanitary conditions for food preparation. This had the potential to affect all residents who resided in the facility and who had received meals from the kitchen. The facility identified a census of 25 residents at the time of the survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05(1) Based on record review and interview; the facility staff failed to provide a notice that gave 3 (Residents 23, 24 and 280) of 3 sampled residents a choice of appeal or not, of Medicare Services ending. The facility staff identified a census of 25.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09C3 Based on record review and interview; the facility failed to complete a discharge summary as required for 1 sampled resident's closed record (Resident 28). The facility census was 25 and the sample size was 1.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Based on observation, record review and interview; the facility failed to wash their hands and change gloves to prevent cross contaminiation during the provision of care for Resident 11 and with a dressing change for Resident 21. The total sample size was 22 and the facility census was 25. A. Review of the facility policy Handwashing/Hand Hygiene with a revised date of 8/19 revealed hand hygiene was the primary means to prevent the spread of infection. The following was identified regarding when staff were to wash hands: -before each resident contact; -after touching a resident or handling their belongings; -whenever hands were soiled; -after any contact with body fluids; -after handling contaminated items; and -before and after gloving. The policy further indicated the following regarding when single-use disposable gloves should be used: [...]