Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sandhills Care Center during CMS and state inspections, most recent first.
The facility failed to maintain proper hand hygiene, monitor dishwasher temperatures, and ensure the cleanliness of food preparation equipment, potentially leading to foodborne illness. Staff were unaware of required temperature levels for sanitation, and improper glove use was observed. The CDM confirmed the absence of cleaning schedules and logs for dishwasher temperature checks.
The facility failed to prevent the spread of infection by not using required PPE during feeding tube care, neglecting hand hygiene during incontinence care and meal service, and not implementing a legionella water management plan.
The facility failed to protect residents from staff-to-resident verbal abuse. Several residents with severe cognitive impairments were roughly handled by a nurse aide (NA-N) during transfers, and another resident was verbally abused by an LPN (LPN-P). Despite assigning retraining, the staff returned to work without completing the required training.
The facility failed to maintain a medication error rate of less than 5%, with errors including crushing medications that should not be crushed, administering medications outside of recommended times, and not ensuring a resident consumed the entire dose. These actions were observed in multiple residents, leading to an error rate of 19.23%, significantly higher than the acceptable threshold.
A resident with severe cognitive impairment was not treated with dignity and respect during care assistance. The resident was addressed in a demeaning manner by an LPN and physically assisted in a way that did not honor their dignity. The Director of Nursing and the Administrator confirmed the incident.
The facility failed to notify a physician of a significant weight loss in one resident and a representative of increased edema, shortness of breath, persistent cough, and new physician orders in another resident. Both residents had severe cognitive impairments and multiple diagnoses, and the facility did not meet its own expectations for timely communication of these changes.
The facility failed to complete a Discharge Recapitulation Summary for a resident who was discharged. The facility's policy requires a comprehensive discharge summary, but a review of the resident's EMR revealed no evidence of its completion. The DON confirmed this omission.
A resident with multiple diagnoses and high fall risk experienced repeated falls due to the facility's failure to identify causal factors and update interventions. Despite having a fall alarm, the resident continued to fall, and staff did not consistently revise or create new interventions to prevent further incidents.
The facility failed to evaluate and address significant weight loss in two residents, leading to a deficiency in providing adequate nutrition and hydration. Despite recommendations for nutritional supplements, the facility did not implement these interventions, and the residents continued to lose weight. Interviews confirmed a lack of awareness and communication regarding the residents' weight loss and the recommended nutritional interventions.
The facility failed to ensure medications were always kept locked, outdated medications were not available for administration, and medications placed for destruction were accounted for until destroyed. Unlogged medications were found in a locked cupboard, and medications scheduled for return were in an unlocked cupboard. Outdated medications were also found in the locked medication refrigerator.
The facility failed to check the Nurse Aide/Medication Aide Registry for findings of abuse, neglect, exploitation, or theft for 4 out of 6 sampled staff members. The Business Office Manager confirmed that these checks were not being performed for all staff members.
Failure to Maintain Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to implement and maintain proper hand hygiene practices, monitor dishwasher temperatures, and ensure the cleanliness of food preparation equipment and surfaces, which could potentially lead to foodborne illness affecting all residents. During an initial kitchen tour, it was observed that there was no log for recording dishwasher temperatures, and staff were unaware of the required temperature levels for proper sanitation. Additionally, the kitchen had soiled and uncleanable surfaces, and the Ninja cooker used for food preparation was heavily soiled with grease and food debris. The Certified Dietary Manager (CDM) confirmed the absence of cleaning schedules for food service equipment and a lack of awareness among staff regarding dishwasher temperature checks. Further observations revealed that a Dietary Aide (DA) did not follow proper hand hygiene and glove use protocols. The DA was seen turning off the water with the same towel used for drying hands, wearing the same gloves while handling various food items and kitchen surfaces, and not changing gloves between tasks. This improper practice was confirmed by the CDM, who acknowledged that staff must perform hand hygiene before and after changing gloves and that gloves must be changed when touching potentially unclean surfaces. Interviews with dietary staff confirmed their lack of awareness regarding the importance of recording dishwasher temperatures and the required temperature levels for proper sanitation. The CDM also confirmed that there was no evidence or log to show that kitchen equipment and surfaces were being cleaned regularly to prevent potential foodborne illness. These deficiencies highlight significant lapses in the facility's food safety and hygiene practices, which could impact the health and safety of all residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to prevent the potential spread of infection due to several lapses in infection control practices. Staff did not wear the required Personal Protective Equipment (PPE) during the care of a resident with a feeding tube. Specifically, a Registered Nurse (RN) administered the feeding tube solution without wearing an isolation gown, which was required under the facility's Enhanced Barrier Precautions (EBP) policy. The RN confirmed a lack of knowledge about the EBP requirements, and the Director of Nurses (DON) and the administrator acknowledged that EBP had not been implemented for the resident or others who met the criteria. Additionally, staff failed to implement proper hand hygiene measures during incontinence care and meal service. During the care of a resident who was incontinent of bowel movement, a Nurse Aide (NA) did not wash or sanitize hands between changing gloves after cleaning the resident's buttocks. This was confirmed by the NA during an interview. Furthermore, staff assisting residents during meal service did not perform hand hygiene between resident contacts, handling multiple residents' utensils and cups without sanitizing their hands in between. The facility also failed to implement a legionella water management plan to prevent potential water-borne illnesses. The facility's policies required a comprehensive water management program, including risk assessments, environmental sampling, and staff education. However, the facility administrator confirmed that no such plan had been identified or implemented. This lack of action was in direct violation of the facility's own policies and procedures aimed at preventing the spread of infections and ensuring a safe environment for residents.
Failure to Protect Residents from Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect the rights of several residents to be free from staff-to-resident verbal abuse. Resident 24, who had severe cognitive impairments and required substantial assistance, was reportedly handled roughly by a nurse aide (NA-N) during a transfer using a sit-to-stand lift. Similarly, Resident 18, also with severe cognitive impairments, was roughly pulled by NA-N during a transfer, causing the resident to voice discomfort. Resident 15, who had severe memory loss and was dependent on staff for all activities of daily living, was also roughly handled by NA-N during a transfer, with the aide using an elbow to keep the resident in position. Despite these allegations, the facility's investigation concluded that NA-N did not intend harm and was unaware of their own strength. NA-N was assigned retraining but returned to work without completing the required training. Another incident involved Resident 9, who was reportedly grabbed and roughly handled by NA-N, leading to the aide's resignation. Additionally, Resident 1, who had severe cognitive impairments, was verbally abused by an LPN (LPN-P) who compared the resident's behavior to that of a 2-year-old and physically assisted the resident in a manner that resulted in bruising. The facility's investigation did not substantiate the abuse allegations but assigned retraining to LPN-P, who also returned to work without completing the required training. The Director of Nursing (DON) and the Administrator confirmed the incidents and the failure of staff to complete the required abuse training before returning to work. The facility's actions and inactions in handling these allegations and ensuring staff training contributed to the deficiency in protecting residents from abuse.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as required by their policies and professional standards of practice. Specifically, the facility staff crushed medications that should not be crushed for two residents, administered medications outside of the recommended times for two other residents, and did not ensure a resident consumed the entire dose of a medication. These actions were observed during medication administration for a sample size of 8 residents, with a facility census of 28 residents. The error rate observed was 19.23%, significantly higher than the acceptable threshold of 5%. Resident 20, who had a feeding tube due to nutritional problems and risk for aspiration, received Tamsulosin HCL in a crushed form, which should not be crushed as it could cause a potential drop in blood pressure. Similarly, Resident 28, who had heart disease and other health issues, received Isosorbide Mononitrate ER in a crushed form, which should be administered whole to prevent adverse side effects. These actions were contrary to the facility's medication administration policy and manufacturer specifications. Additionally, Resident 1, who was confused and forgetful, received Omeprazole after consuming 75% of breakfast, instead of 30 minutes before the meal as required. The same resident was also given Wheat Dextrin without ensuring the entire dose was consumed. Resident 26, who had physical and cognitive limitations, received Pantoprazole after consuming 100% of the meal, instead of 30-60 minutes before the meal. These deviations from the prescribed medication administration times and procedures were confirmed by the Director of Nursing during an interview, highlighting the facility's failure to adhere to its own policies and professional standards of practice.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat Resident 1 with dignity and respect during care assistance. Resident 1, who had severe cognitive impairment due to non-traumatic brain dysfunction, Alzheimer's, dementia, and depression, required partial to moderate assistance with toileting, dressing, and personal hygiene. On 5/5/24, when Resident 1 was incontinent, LPN-P documented that the resident slapped NA-Y during an attempt to assist the resident in getting dressed. LPN-P then addressed the resident in a demeaning manner, comparing their behavior to that of a 2-year-old and insisting that the resident could either get up on their own or be assisted by LPN-P and NA-Y. The resident, who was resistive, was then physically assisted into a seated position on the bed and subsequently ambulated to the bathroom and later to the dining room for breakfast. The Director of Nursing and the Administrator confirmed during an interview on 5/21/24 that Resident 1 was not treated with respect and dignity by LPN-P on 5/5/24. The facility's list of Resident's Rights, which is provided to each resident and/or their responsible party upon admission, states that all residents have the right to be treated with respect and dignity. This incident highlights a failure to uphold these rights, as evidenced by the inappropriate and disrespectful manner in which LPN-P interacted with Resident 1 during care assistance.
Failure to Notify Physician and Representative of Resident Changes
Penalty
Summary
The facility failed to notify Resident 11's physician of a significant weight loss and Resident 24's representative of increased edema, shortness of breath, persistent cough, and new physician orders related to the resident's change in condition. Resident 11, who had severe cognitive impairment and multiple diagnoses including dementia and cancer, experienced a weight loss of 22 lbs. over six months. Despite the facility's policy requiring staff to report significant weight losses to the physician, there was no evidence that Resident 11's physician was notified of this weight loss. The resident's care plan indicated a risk for nutritional decline and required extensive staff assistance with eating, but the necessary communication with the physician was not documented. Resident 24, who also had severe cognitive impairment and diagnoses including heart failure and dementia, exhibited increased edema, shortness of breath, and a persistent cough. Although the resident's physician was notified and new orders were received, there was no evidence that the resident's representative was informed of these changes and new orders. The facility's Director of Nursing confirmed that there was no policy related to notification of change for a physician and/or responsible party, and that the charge nurses were expected to notify the resident's physicians and representatives within 24 hours of a change in condition. The facility failed to meet these expectations for both residents, leading to the identified deficiencies.
Failure to Complete Discharge Recapitulation Summary
Penalty
Summary
The facility failed to complete a Discharge Recapitulation Summary for Resident 29, who was admitted on an unspecified date and discharged on 4/17/24. The facility's policy, revised in October 2022, mandates that a discharge summary and post-discharge plan be developed for anticipated discharges. This summary should include comprehensive details such as diagnoses, medical history, treatment, functional status, and medication reconciliation. However, a review of Resident 29's Electronic Medical Record (EMR) revealed no evidence of a completed discharge summary. The Director of Nursing (DON) confirmed during an interview on 5/22/24 that the comprehensive Discharge Recapitulation Summary was not completed for Resident 29.
Failure to Prevent Ongoing Falls for High-Risk Resident
Penalty
Summary
The facility failed to identify causal factors and develop or revise interventions to prevent ongoing falls for a resident identified as high risk for falls. The resident, who had diagnoses including osteoarthritis, atrial fibrillation, heart failure, non-Alzheimer's dementia, anxiety, and depression, experienced multiple falls over several months. Despite the resident's high fall risk score and repeated incidents, the facility did not consistently update or create new interventions to address the falls effectively. For instance, after falls on 2/3/24, 3/10/24, 3/20/24, and 4/26/24, staff did not determine causal factors or revise current interventions. The resident's fall incidents included situations where the fall alarm was either not functioning or not responded to in a timely manner. On 1/19/24, the resident fell in the dining room despite having a fall alarm in place. On 2/3/24, the resident fell out of a chair, and the incident report noted that nothing could be done to avoid future falls, with no causal factors identified. On 3/10/24, the resident was found on the floor by the Nurse's Station, but no new interventions were developed. Similar patterns were observed in subsequent falls, with staff failing to revise interventions or identify new ones. The Director of Nursing confirmed that the resident was at high risk for falls and that the fall alarm was sometimes rendered dysfunctional due to the resident's restlessness. Despite this, the facility continued to use the alarm without ensuring its consistent functionality. The DON also verified that staff were supposed to develop new interventions or revise current ones with each fall, but this was not done consistently. The lack of timely and effective intervention updates contributed to the ongoing falls and potential injuries for the resident.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and address significant weight loss in two residents, leading to a deficiency in providing adequate nutrition and hydration. Resident 11, who had severe cognitive impairment and multiple diagnoses including dementia and cancer, experienced a weight loss of 12% over six months. Despite the Registered Dietician's recommendation for a Complete Nutrition Supplement (CNS), the facility did not implement this intervention, and the resident continued to lose weight. Observations revealed that the resident was not provided with the CNS during meals, and there was no documented evidence that the supplement was given as recommended by the RD. Resident 15, who also had severe cognitive impairment and was totally dependent on staff for assistance, experienced a weight loss of 17.07% over six months. The resident had a physician's order for a nutritional supplement to be given if meal consumption was 50% or less. However, the facility failed to document the resident's meal intake percentages and the amount of nutritional supplement provided. Multiple instances were noted where the resident ate less than 50% of their meals, but no supplement was documented as given. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Dietary Manager (DM) confirmed the lack of awareness and communication regarding the residents' weight loss and the recommended nutritional interventions. The facility's failure to monitor, document, and implement appropriate nutritional interventions contributed to the ongoing weight loss in both residents, highlighting a significant deficiency in the facility's care practices.
Medication Storage and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure medications were always kept locked, outdated medications were not available for administration, and medications placed for destruction were accounted for until destroyed. During an observation of the medication storage, it was found that there was no accounting or logged amounts of the current medication placed for destruction in a locked cupboard at the nurse's station. Various unlogged medications, including Spiriva inhaler, Colace, multivitamin tablets, Aspirin, Requip, Nicotine patches, Pain Relief tablets, Eliquis, Zofran, Nitroglycerin, Novolog insulin, Levemir insulin, Acetaminophen, lidocaine patches, Lasix, Nyst/Hydrac/Zinc cream, Breo, Voltaren gel, and Antacid were present in the cupboard. Additionally, medications scheduled to be returned to the pharmacy were observed in an unlocked cupboard at the nurse's station, including Trazadone, Olanzapine, Bumetanide, Anti-diarrheal, Tylenol, Ibuprofen, and Zoloft tablets. Furthermore, outdated medications were found in the facility's locked medication refrigerator, including Tuberculin injectable and COVID-19 vaccine, which were still available for use despite being past their expiration dates. Interviews with the LPN and DON confirmed that all outdated medications should not be available for administration and should be placed for destruction. The DON also confirmed that all facility medications were to be locked and secure at all times while being stored in the facility. The medications scheduled to be returned to the pharmacy had been stored in an unlocked cabinet at the nurse's station, and the medications that had been discontinued and stored in a locked cabinet at the nurse's station had not been logged to ensure accountability for those medications in the interim between the time they were placed in the cabinet and the time when they would be destroyed. The facility's policies on medication storage and destruction of unused drugs were not adhered to, leading to these deficiencies.
Failure to Check Nurse Aide/Medication Aide Registry for Staff
Penalty
Summary
The facility failed to check the Nurse Aide/Medication Aide Registry for findings of abuse, neglect, exploitation, or theft for 4 out of 6 sampled staff members. Personnel files reviewed on May 23, 2024, showed no evidence that the registry was checked for a Housekeeping/Laundry staff member, an LPN, a Dietary Aide, and a Domestic Aide. During an interview on the same day, the Business Office Manager confirmed that the facility was not performing these checks for all staff members.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ainsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rock County Hospital Long Term Care | 15.9 mi | ★★★★★ | 8 | 0 |
| Parkside Manor | 36 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.