Sage Creek Post-Acute

In the surveyor’s words

From the most serious findings on record at Sage Creek Post-Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Aug 4, 2021

  Based on observations, interviews and document review, the facility failed to ensure appropriate infection control measures to prevent and/or contain the spread of COVID-19 was implemented as evidenced by 1) a staff member entered a transmission-based precaution room without a gown and gloves, 2) a housekeeper was cleaning a transmission-based precaution room in the Yellow Unit (Observation Unit) without the proper personal protective equipment (PPE), 3) a housekeeper was observed cleaning a transmission-based precaution room without appropriate PPE prior to cleaning a COVID negative room, and 4) 12 of 12 direct and indirect staff members working in the Yellow Unit (Observation Unit) were not fit tested for an N95 mask. […]

• No harm, potential for more than minimal, widespreadF887Aug 4, 2021

  Based on interviews, record review and document review, the facility failed to ensure appropriate infection control measures to prevent and/or contain the spread of COVID-19 was implemented as evidenced by COVID-19 vaccination was not being offered to the staff members and 7 of 10 sampled and unsampled residents (Resident #1, #2, #5, #6, #7, #9, and #10). Findings include: The facility's policy titled Coronavirus (COVID-19) Vaccine Plan & Policy (undated) documented the vaccination was a tool in a broad-based strategy including ongoing source control within the skilled nursing facilities to prevent the spread of COVID-19. […]

• No harm, potential for more than minimal, patternF676May 26, 2022

  Based on observation, interview, record review, and document review, the facility failed to ensure personal hygiene assistance was provided for 4 of 6 sampled residents (Resident #2, #3, #4, and #5) and showers were provided for 2 of 6 sampled residents (Resident #1 and #2). Findings include: 1) Personal hygiene assistance not provided Resident #2 (R2) R2 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) assessment dated [DATE], revealed R2 required extensive assistance for personal hygiene. On 05/25/2022 at 8:50 AM, R2 was observed with a scruffy beard and moustache. R2 indicated having made multiple requests from the nursing staff to be shaved. […]

• No harm, potential for more than minimal, patternF694Nov 23, 2021

  Based on observation, interview, record review and document review, the facility failed to ensure peripherally inserted central catheter (PICC) site dressings were changed in accordance with facility policy and procedure, were properly labeled, and/or the PICC line was removed in accordance with a physician order, for 2 of 5 sampled residents with PICC lines (Residents 89 and 202); and peripheral intravenous catheters (PIV) were ordered by a physician, were properly labeled, monitored for signs of infection, and flushed to keep open in accordance with facility policy and procedure for 2 of 6 sampled residents with [MEDICATION(S)] locks (Residents 199 and 203) . […]

• No harm, potential for more than minimal, patternF825Nov 23, 2021

  Based on observation, interview, record review and document review, the facility failed to ensure specialized rehabilitation service or speech therapy services were available prior to admitting new residents with compromised swallowing functions and provided in a timely manner for 3 of 6 sampled residents (Resident #103, #110, and #310). Findings include: The facility policy titled Specialized Rehabilitative Services revised 12/2009, indicated the facility would provide rehabilitative services to residents as indicated to include Speech Pathology (study and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #103 (R103) R103 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]