Sage Bluff Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Sage Bluff Health and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jun 28, 2021

  Based on interview, and record review, the facility failed to follow infection control practices for following guidance given by the local health department as requested for contact tracing and failed to follow-up timely for potential exposure when the facility had been notified of an admitted resident (Resident D) with a TB ([CONDITION(S)]) infected bone graft. This deficiency had the potential to impact 50 of 50 residents residing in the facility and any staff who were exposed to receive timely testing and treatment, with a potential impact to others outside of the facility resulting in immediate jeopardy. […]

• Immediate jeopardy, isolatedF689May 27, 2022

  Based on interview and record review the facility failed to ensure safe use of an assistive grab bar by assessing an air mattress for safe use for a resident when a new mattress was provided. This resulted in resident death for 1 of 3 residents reviewed. The immediate jeopardy began on [DATE] when the facility failed to assess a resident in the use of a new mattress with an assistive device (grab bar) to prevent entrapment after delivery of the mattress. The Executive Director, Director of Nursing Services, and Clinical Nursing Consultants were notified of the immediate jeopardy at 2:14 PM on [DATE]. […]

• Actual harm, isolatedF692Apr 6, 2022

  Based on observation, interview, and record review, the facility failed to act upon a significant weight loss and develop personalized interventions for a resident at risk for weight loss (Resident B) for 1 of 3 residents reviewed for weight loss. This deficient practice resulted in the resident experiencing a 26% loss of weight in 5 weeks with no interventions put into place. Finding include: During an initial observation on 4/4/22 at 9:10 a.m., Resident B was noted in bed. The enteral feeding bag next to his bed was empty. During wound care observation on 4/4/22 at 12:23 p.m. with Unit Manger 2, Resident B was noted to be emaciated. He had two wounds that were healing on his sacrum and right hip. The clinical record for Resident B was reviewed on 4/4/22 at 9:40 a.m. […]

• No harm, potential for more than minimal, widespreadF887Apr 6, 2022

  Based on observation, interview and record review, the facility failed to ensure the vaccination matrix listed all staff and contracted staff with their vaccination status and doses administered for Covid-19. Finding include: During review of the staff matrix on 4/5/22 at 10:35 a.m., several staff were noted on the schedule and not on the matrix. The information was compared to the binder provided by the Corporate Nurse. Several staff did not have a current vaccination status on file. The total number of staff on the matrix was 47. During an interview on 4/5/22 at 10:50 a.m., the Corporate Nurse indicated they were currently using approximately 8 different agencies. She was not aware all the staff they were using needed to be on the matrix. […]

• No harm, potential for more than minimal, widespreadF888Apr 6, 2022

  Based on observation, interview and record review, the facility failed to ensure the staff vaccination was complete and accurate for Covid-19. Finding include: During review of the staff matrix on 4/5/22 at 10:35 a.m., several staff were noted on the schedule and not on the matrix. The information was compared to the binder provided by the Corporate Nurse. Several staff did not have a current vaccination status on file. The total number of staff on the matrix was 47. During an interview on 4/5/22 at 10:50 a.m., the Corporate Nurse indicated they were currently using approximately 8 different agencies. She was not aware all the staff they were using needed to be on the matrix. She indicated they could try and find their vaccination cards. […]