Inspection Reports for Sandhills Care Center
143 N Fullerton Street, AINSWORTH, NE, 69210
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
50% occupied
Based on a May 2019 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Capacity: 46
Deficiencies: 0
Feb 4, 2025
Visit Reason
The document serves as a renewal application for the nursing home license of Sandhills Care Center and includes related licensing and occupancy permits.
Findings
The documents verify that Sandhills Care Center is licensed through the renewal date and meets statutory requirements for licensure and occupancy with a capacity of 46 beds.
Report Facts
Total licensed beds: 46
Renewal license fee: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Jacobs | Administrator | Named as facility administrator on renewal application and administrator page |
| Sara Mayhew | Director of Nursing | Named as director of nursing on renewal application |
| Thomas E. Jones | Chairman | Authorized representative signing renewal application |
| Robert Folck | Deputy State Fire Marshal | Inspected facility for occupancy permit |
Inspection Report
Routine
Census: 23
Capacity: 46
Deficiencies: 9
May 8, 2019
Visit Reason
Routine state inspection survey of Sandhills Care Center to assess compliance with regulatory requirements including quality of care, nutrition, infection control, emergency power, fire safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to provide adequate wound care and monitoring for residents with wounds, failure to implement nutritional interventions to prevent weight loss, lapses in infection prevention and control practices including catheter care and medication administration, failure to maintain emergency power system testing, fire safety deficiencies including obstructed exit corridors and malfunctioning corridor doors, inadequate fire drill frequency, and improper signage for oxygen use in resident rooms.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide treatment and monitoring to ensure wound healing for 2 sampled residents (Residents 4 and 22). | SS=D |
| Failed to implement current nutritional interventions and revise or develop additional interventions for prevention of weight loss for 2 sampled residents (Residents 12 and 19). | SS=D |
| Failed to establish and maintain an infection prevention and control program including proper catheter care, wound care, medication administration, and glucometer disinfection. | SS=E |
| Failed to conduct monthly testing of electrolyte specific gravity of the batteries for the emergency generator. | — |
| Failed to maintain exit corridors free of obstructions; recliner chair was blocking corridor width. | — |
| Failed to maintain fire sprinkler system free of dust and lint. | — |
| Failed to maintain corridor doors to ensure smoke separation; kitchen door did not fully close and latch. | — |
| Failed to conduct one fire drill per shift per quarter during the last 12 months. | — |
| Failed to use proper signage on resident room doorways where oxygen was in use. | — |
Report Facts
Facility census: 23
Total capacity: 46
Deficiency count: 9
Weight loss: 3
Weight loss: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-D | Licensed Practical Nurse | Named in findings related to wound care deficiencies and infection control lapses |
| NA-C | Nurse Aide | Named in findings related to catheter care deficiencies |
| Dietary Manager | Dietary Manager | Named in findings related to nutritional interventions and audits |
| Director of Nursing | Director of Nursing | Named in multiple findings and responsible for corrective actions and audits |
| Maintenance Staff A | Maintenance Staff | Named in findings related to fire safety and emergency power system deficiencies |
| Administrative Staff A | Administrator | Named in findings related to fire safety and emergency power system deficiencies |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Oct 1, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Sandhills Care Center regarding failure to identify a change of condition and failure to use fall interventions to prevent injuries.
Findings
The facility was found to have no violation related to identifying changes in resident conditions but failed to implement fall prevention interventions for one resident, resulting in a violation of Federal tag F 689 and Licensure Reference Number 175 NAC 12-006.09D7.
Complaint Details
The complaint alleged the facility failed to identify a change of condition and failed to use fall interventions to prevent injuries. The facility was substantiated for failure to use fall interventions but not for failure to identify changes in condition.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to use fall interventions to prevent injuries for one resident with a history of falls. | SS=D |
Report Facts
Facility census: 20
Residents sampled: 3
Resident falls: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Stephanie Rucker | Administrator | Facility administrator addressed in the report |
Inspection Report
Routine
Census: 20
Capacity: 46
Deficiencies: 9
Feb 13, 2018
Visit Reason
Routine state inspection survey of Sandhills Care Center to assess compliance with federal and state regulations including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to provide restorative therapy as recommended, inadequate fall prevention interventions, improper medication storage and handling, fire safety code violations including delayed egress door malfunction, improperly installed fire extinguishers, corridor door latching and sealing issues, inadequate fire drill scheduling, and improper storage and labeling of oxygen cylinders.
Severity Breakdown
SS=D: 2
SS=E: 4
SS=F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to provide restorative therapy for Resident 4's contracture as recommended by Occupational Therapist. | SS=D |
| Failure to identify causal factors and develop additional interventions for prevention of falls for Residents 10, 5, and 22. | SS=E |
| Failure to develop interventions to address Resident 10's urine incontinence. | SS=D |
| Medication carts left unlocked and unattended with medications left on top unattended. | SS=E |
| Magnetically locked delayed egress exit door failed to release lock within 15 seconds upon application of force. | SS=E |
| Portable fire extinguisher installed with top more than five feet above finished floor. | SS=F |
| Corridor doors failed to positively latch and seal within door frame, allowing potential smoke passage. | SS=F |
| Fire drills not conducted under varied conditions; drills not spaced at least one hour apart on same shift. | SS=F |
| Oxygen cylinders not labeled as full or empty and empty cylinders not segregated from full ones. | SS=E |
Report Facts
Facility census: 20
Total licensed capacity: 46
Sample size: 18
Falls: 7
Fire drills: 4
Fire drills: 8
Fire extinguisher height: 60.75
Door gap: 0.5
Force applied to delayed egress door: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Confirmed delayed egress door malfunction and fire drill scheduling issues | |
| Director of Nursing | Verified lack of restorative therapy, fall prevention interventions, incontinence interventions, medication storage policies, oxygen cylinder storage, and monitoring processes | |
| Licensed Practical Nurse C | Observed leaving medication cart unlocked and unattended during medication pass | |
| Registered Nurse E | Observed leaving medication cart unlocked and unattended during medication pass | |
| Administrative Staff A | Confirmed fire extinguisher height and corridor door issues |
Inspection Report
Renewal
Capacity: 46
Deficiencies: 0
Feb 8, 2018
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related renewal certification for Sandhills Care Center, verifying licensure through the renewal date and requesting renewal of the facility license.
Findings
The documents confirm that Sandhills Care Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility with 46 beds, including certification for Medicare and Medicaid services and special care treatments such as physical, speech, and occupational therapy.
Report Facts
Total licensed beds: 46
Facility square footage: 13777
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Rucker | Administrator | Named as facility administrator on licensure renewal application and administrator listing |
| Chelsea Hladyk | Director of Nursing, R.N. | Named as Director of Nursing on licensure renewal application |
Notice
Capacity: 46
Deficiencies: 0
Mar 1, 2017
Visit Reason
Notification that Sandhills Care Center has been accepted to participate under the Medicare Health Insurance Benefits Program, with details about certification and ongoing unannounced surveys.
Findings
The letter informs the facility of its Medicare certification status, the requirement for compliance with Civil Rights and regulatory standards, and the process for ongoing unannounced surveys and plans of correction if deficiencies are found.
Report Facts
Medicare certified beds: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the letter as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS. |
Inspection Report
Annual Inspection
Census: 3
Capacity: 46
Deficiencies: 11
Nov 22, 2016
Visit Reason
Annual inspection of Sandhills Care Center to assess compliance with Nebraska Administrative Code and Life Safety Code requirements.
Findings
The facility was found deficient in developing comprehensive care plans addressing resident risks, specifically for Resident 2's risk of injury from hot liquid spills. Life safety deficiencies included missing signage on delayed egress doors, lack of emergency lighting controls, unsealed hazardous area penetrations, missing fire extinguisher instructions, incomplete fire alarm inspection documentation, improper electrical supply to fire sprinkler compressor, smoke barrier penetrations and doors not resisting smoke passage, and incomplete generator testing documentation.
Severity Breakdown
SS=F: 8
SS=D: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan addressing Resident 2's risk of injury from hot liquid spills. | — |
| Failed to implement interventions to prevent hot liquid spills for Resident 2 at risk for spilling hot liquids. | — |
| Delayed egress exit doors lacked required signage describing steps necessary to open the door. | SS=F |
| Emergency lighting could be turned off by a switch, risking loss of emergency lighting during power outage. | SS=F |
| Hazardous areas not properly enclosed: opening in food storage pantry wall, soiled linen door failed to latch, housekeeping closet had kick down door stop. | SS=F |
| Missing placard with operating instructions for Class K portable fire extinguisher in kitchen. | SS=D |
| Incomplete documentation for annual fire alarm system inspection; missing serial numbers of devices. | SS=F |
| Fire sprinkler system air compressor powered through a switched power supply, risking low air supply and damage. | SS=F |
| Smoke barrier in attic had unsealed penetrations and non-smoke resistant access door. | SS=F |
| Smoke barrier doors in Hall 3 had gaps greater than 1/4 inch, not resisting smoke passage. | SS=F |
| Emergency generator lacked documentation of monthly load testing. | SS=F |
Report Facts
Facility census: 3
Total licensed capacity: 46
Resident sample size: 3
Hot Beverage Safety Evaluation score: 4
Coffee temperature: 170
Coffee temperature limit: 150
Fire sprinkler system air compressor switch removal date: Dec 6, 2016
Delayed egress door signage completion date: Nov 30, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Rucker | Administrator | Signed facility census and capacity form |
| Patricia Wolfe | Surveyor | Conducted inspection and signed compliance form |
| Maintenance A | Verified multiple life safety deficiencies during interview | |
| Director of Nurses | DON | Confirmed Resident 2's risk and lack of care plan interventions |
| Consultant Dietary Manager | CDM | Checked coffee temperature and discussed hot liquid safety |
| Administration A | Verified fire alarm and generator documentation deficiencies |
Notice
Capacity: 46
Deficiencies: 0
Nov 2, 2016
Visit Reason
Issuance of a Nebraska Skilled Nursing Facility license to Sandhills Care Center and notification of license expiration and renewal process.
Findings
The facility met the requirements for licensure as a skilled nursing facility. A license was issued with an expiration date of March 31, 2017.
Report Facts
Number of beds licensed: 46
License expiration date: Mar 31, 2017
License issuance date: Nov 2, 2016
Initial license fee: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Rucker | Administrator | Named as facility administrator on license application and in correspondence. |
| Thomas L. Williams | Chief Medical Officer, Director, Division of Public Health | Signed the license issuance letter and renewal notice. |
| Eve Lewis | Program Manager | Contact person for questions about the license. |
| Ron Ross | President, Rural Health Development | Signed letter submitting license application. |
Inspection Report
Original Licensing
Deficiencies: 0
Nov 2, 2016
Visit Reason
The inspection was conducted for initial licensure of the nursing home as per Title 175, Chapter 12 regulations.
Findings
The facility was found to be in compliance with the regulations for skilled nursing facilities, nursing facilities, and intermediate care facilities for initial licensure.
Notice
Capacity: 46
Deficiencies: 0
APP2017
Visit Reason
This document serves as a license renewal notification for Sandhills Care Center and includes the occupancy permit indicating the maximum licensed capacity of the facility.
Findings
The document certifies that Sandhills Care Center meets statutory requirements for SNF/NF dual certification and provides the occupancy permit with a maximum capacity of 46 beds.
Report Facts
Licensed beds: 46
Renewal fee: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Rucker | Administrator | Named as administrator on the renewal application |
| Amanda Tucker | Director of Nursing | Named as director of nursing on the renewal application |
Notice
Capacity: 46
Deficiencies: 0
APP2019
Visit Reason
This document serves to verify the renewal of the SNF/NF dual certification license for Sandhills Care Center and includes the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The facility is licensed as a skilled nursing/nursing facility with a total licensed capacity of 46 beds. The Nebraska State Fire Marshal issued an occupancy permit confirming a maximum occupancy of 46 beds.
Report Facts
Licensed capacity: 46
Renewal fee: 1550
Date issued: Feb 8, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Rucker | Administrator | Named as facility administrator in licensure renewal application. |
| Chelsea Hladky | Director of Nursing | Named as Director of Nursing in licensure renewal application. |
| J. Philip Fuchs | Interlocal Board Member | Listed as a board member of the Ainsworth/Brown County Care Center. |
Document
Capacity: 46
Deficiencies: 0
APP2020
Visit Reason
This document serves to verify the renewal of the SNF/NF dual certification license for Sandhills Care Center and provides facility details including ownership, capacity, and fire marshal occupancy permit.
Findings
The document confirms that Sandhills Care Center meets statutory requirements for licensure through the renewal date and provides administrative and facility information including licensed bed capacity and fire marshal occupancy approval.
Report Facts
Licensed beds: 46
License expiration date: Mar 31, 2021
Facility square footage: 13777
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Kinzie | Administrator | Listed on facility information page |
| Chelsea Hladky | Director of Nursing | Listed on facility information page |
| J. Philip Fuchs | Authorized Representative | Signed application for license |
| Stephanie Rucker | Administrator | Listed as administrator on page 3 |
Document
Capacity: 46
Deficiencies: 0
APP2021
Visit Reason
The document set serves to renew the nursing home license for Sandhills Care Center and includes related administrative and occupancy permit information.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal application details, facility ownership, administrator, and occupancy permit status.
Report Facts
Total licensed beds: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Jacobs | Administrator | Named as facility administrator on renewal application and facility information page |
| J. Philip Fuchs | Authorized Representative | Signed the renewal application as authorized representative |
| Robert Flock | Deputy State Fire Marshal | Inspected the facility for occupancy permit |
Notice
Capacity: 46
Deficiencies: 0
APP2022
Visit Reason
This document set includes a nursing home licensure renewal application and related certification and occupancy permit for Sandhills Care Center.
Findings
The documents certify that Sandhills Care Center meets statutory requirements for SNF/NF dual certification and includes approval for occupancy with a maximum capacity of 46 beds.
Report Facts
Total licensed beds: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Jacobs | Administrator | Named as Administrator of Sandhills Care Center in renewal application and facility information. |
| Mary Brenda Garvin | Director of Nursing | Named as Director of Nursing in renewal application. |
| J. Philip Fuchs | Authorized Representative | Signed the renewal application as authorized representative. |
| Robert Flock | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Notice
Capacity: 46
Deficiencies: 0
APP2023
Visit Reason
The document serves as a renewal application for the nursing home license of Sandhills Care Center and includes verification of licensure and occupancy permit information.
Findings
The documents confirm that Sandhills Care Center is licensed and certified for Medicare and Medicaid, with 46 licensed beds, and holds an occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Number of beds to be relicensed: 46
Maximum Occupancy: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Jacobs | Administrator | Named as Administrator on the Nursing Home Licensure Renewal Application and on page listing. |
| Michele Schafer | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application. |
| J. Philip Fuchs | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Robert Flock | Deputy State Fire Marshal | Approved the Nebraska State Fire Marshal Occupancy Permit. |
Document
Capacity: 46
Deficiencies: 0
APP2024
Visit Reason
The documents pertain to the renewal of the nursing home license for Sandhills Care Center, including submission of the renewal application and confirmation of licensed bed capacity.
Findings
No inspection findings or deficiencies are reported. The documents certify licensure renewal and occupancy permit compliance for 46 beds.
Report Facts
Number of beds to be relicensed: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Jacobs | Administrator | Named as Administrator on the renewal application and facility information |
| Sara Mayhew | Director of Nursing | Named as Director of Nursing on the renewal application |
| Thomas E. Jones | Chairman | Signed as authorized representative on the renewal application |
| Robert Flock | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit |
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