Sarah Ann Hester Memorial Home

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(G) Based on record review and interview, the facility failed to complete and submit a thorough investigation for 1 (Resident 2) of 3 residents' reportable incidents. The facility idenitifed a census of 30 residents. A record review of Resident 2's face sheet revealed they were admitted to the facility on [DATE]. A record review of a facility-provided document titled, Diagnosis list, revealed Resident 2's medical diagnoses included weakness, dementia (a condition affecting memory, thinking, and ability to perform daily activities), chronic obstructive pulmonary disease (a lung disease which restricts breathing), ataxic gait (unsteady walking which often has a neurological cause), and osteoarthritis (a joint disease that causes pain, stiffness, and reduced mobility). [...]

Inspectors wroteLicensure Reference Number 12-006.11(E) Based on observation, interview, and record review, the facility failed to ensure use or disposal of foods prior to expiration dates, maintenence and cleaning of resident refrigerators, and sanitizing solutions were at the required strength per manufacturers instructions. The facility also failed to ensure use of gloves during meal preparation as indicated. This had the potential to affect all 31 residents.

Inspectors wroteLicensure Reference Number 175 NAC 1-006.05(S) Based on observations, interviews, and record review; the facility failed to maintain 3 (Residents 2, 8, and 37) of 3 sampled residents' dignity by ensuring their urinary catheter bags were not visible to others while the residents were in their rooms. The facility census was 32. Findings Are: A record review of the facility policy Nursing/Catheter Usage revised 2/9/2026 revealed catheter tubing and bag were to be kept off of the floor and that the catheter bag was to be encased in a catheter bag pouch or cover anytime the resident was up and about in the facility. A record review of an undated, facility-provided document titled Resident Rights revealed all residents are to be afforded a dignified existence. A. A record review of Resident 8's Facesheet revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G)(i)(7) Based on record review and interview, the facility failed to complete a recapitulation of stay and failed to notify the ombudsman upon discharge for 1 (Resident 35) of 1 sampled resident. The facility census was 32. Findings Are: A record review of Resident 35's Facesheet revealed the resident was admitted to the facility on [DATE]. A record review of Resident 35's Post-Discharge Plan of Care dated 1/28/2026 revealed the resident was discharged to their family member's home on 1/28/2026. A.A record review of Resident 35's medical records revealed no evidence of a recapitulation of stay being completed for the resident. An interview on 4/01/2026 at 9:45 AM with the Director of Nursing (DON) confirmed a recapitulation of stay was not completed for Resident 35. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.04 (A)(iii)Based on record review and interview, the facility failed to complete a criminal background check on 1 of 5 sampled employees and failed to complete sex offender and nurse aide registry checks for 1 of 5 sampled employees. This had the potential to affect all 32 residents in the facility. Record review of an undated facility-provided document revealed a list of facility staff which included name, hire date, and title of all regular facility staff. The document also revealed Dietary Aide-A (DA-A) had a hire date of 3/2/26 and Housekeeper-B (HSK-B) had a hire date of 2/24/26. A.A record review of DA-A's employee file revealed no documentation that a criminal background check was performed. [...]

Inspectors wroteLicensure Reference Number 12-006-09(F) Based on record reviews and interviews, the facility failed to ensure Comprehensive Care Plans (CCP) were updated with fall interventions for 2 (Resident 2 and Resident 4) of 4 sampled residents. The facility staff identified a census of 32.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation and interviews the facility failed to thoroughly clean and sanitize food surfaces after preparation of raw chicken. This affected all the residents. The facility identified a census of 30. An observation of meal preparation on 1/14/25 from 10:10 AM to 10:30 AM with Cook-I revealed Cook-I obtaining raw chicken breast in a tote from the lower shelf in the refrigerator and brought the raw chicken over to a food preparation table. Cook-I retrieved a large metal baking sheet and placed it on a food preparation counter near the chicken but not directly next to the chicken. Cook-I then performed hand hygiene for 20 seconds with soap and water and applies gloves. Using scissors, Cook-I cuts the bag of raw chicken open and discards the scissors into a dirty sink. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.09(E) Based on record reviews and interviews, the facility failed to develop person-centered comprehensive care plans for 3 (Residents 1, 6, and 20) of 12 sampled residents. The facility identified a census of 30.

Inspectors wroteLICENSURE REFERENCE 175 NAC 12-006.09(H) Based on record review and interview the facility failed to ensure that 3 (Residents 2, 17, and 20) of 6 sampled residents' antibiotics had a duration or a stop date. The facility identified a census of 30.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(H) Based on record reviews and interview, the facility failed to ensure the physician provided a written clinical rationale for declined gradual dose reductions (GDRs, tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) for 6 (Residents 13, 16, 17, 20, 23, and 31) of 6 sampled residents. The facility identified a census of 30.

Inspectors wroteLicensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to ensure 3 of 5 sampled employees had completed at least 12 hours of ongoing training as required. This had the potential to affect all 30 residents residing within the facility.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview the facility failed to ensure that one (Resident 1) of 2 sampled resident's representative were notified of restraint use, duration, and alternatives. The facility identified a census of 30.

Inspectors wroteLicensure Reference 175 NAC 12-006.18 Based on observations, interviews, and record reviews; the facility staff failed to don Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) during high-risk care activities for 1 (Resident 13) of 1 sampled resident. The facility identified a census of 30.

Inspectors wroteLicensure Reference 175 NAC 12-006.04(A)(iii)(2) Based on record reviews and interview, the facility failed to complete a nurse aide registry check for 1 of 3 sampled employees prior to the staff having unsupervised contact with the residents. The facility staff identified a census of 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review; the facility kitchen staff failed to label and date opened packages of food and drink in the refrigerator, freezer, and dry storage to prevent the potential for food borne illness. This had the potential to affect all residents. The facility census was 28.

Inspectors wroteBased on observation, record review and interviews; the facility failed to perform hand hygiene to prevent the potential spread of infection for 4 (Resident's 13, 5, 1, 6) of 4 sampled residents. The facility identified a census of 28.

Inspectors wroteB. Record review of Resident 23's Face Sheet revealed Resident 23 was admitted to the facility on [DATE] with diagnoses of: weakness, abnormalities of gait and mobility, Alzheimer's disease, shortness of breath, hypoxemia, disorientation, and orthostatic hypotension. A record review of Resident 23's quarterly MDS dated [DATE], revealed Resident 23 had a BIMs score of 10, which revealed the resident had moderate cognitive impairment. The MDS also revealed Resident 23 had delusions. The MDS indicated no falls since last assessment and no therapy has been completed. The MDS indicated a bed alarm, chair alarm, and wander alarm were used less than daily. A record review of Resident 23's active physician's order, dated 11/28/2023 were: [...]