Sage Creek Post-Acute

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident's care plan was reviewed and updated following an actual fall for 1 of 2 sampled residents (Resident 2). The deficient practice placed the resident at risk for repeated falls.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure an elderly resident did not leave facility premises without supervision or authorization and post-elopement prevention measures were adequately performed for 1 of 2 sampled residents (Resident 2). The deficient practice resulted in the resident falling in a nearby shopping complex resulting in hospitalization.

Inspectors wroteBased on observation, interview, record review and document review the facility failed to ensure: 1) a sequential compression device (SCD- a device used to prevent blood clots by promoting blood circulation) was accurately documented, applied and in use as ordered by the physician for 1 of 32 sampled residents (Resident 8) and 2) a physician order for fluid restriction was followed for 1 of 32 sampled residents (Resident 2). The deficient practice had the potential to place residents at risk for blood clot formation and electrolyte imbalance.

Inspectors wroteBased record review, document review, and interview, the facility failed to communicate an episode of shortness of breath requiring intervention to the hemodialysis clinic prior to treatment for 1 of 32 sampled residents (Resident 28). The deficient practice had the potential for the hemodialysis provider to initiate treatment without knowledge of the resident's recent symptoms, which could have impacted treatment decisions and placed the resident at risk for complications.

Inspectors wroteBased on observation, record review, interview, and document review, the facility failed to obtain physician orders for the insertion, use, and monitoring of a peripheral intravenous (IV) catheter, and failed to ensure IV site care and dressing requirements were followed for 1 of 32 sampled residents (Resident 23). The deficient practice had the potential to result in complications related to improper IV management, including infection, infiltration, or other adverse outcomes such as phlebitis.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a completed Physician Orders for Life-Sustaining Treatment (POLST) form reflecting the resident's do not resuscitate (DNR) status was obtained and maintained in the medical record for 1 of 18 sampled residents (Resident 147). The failed practice had the potential to result in the resident not receiving care consistent with the resident's resuscitation preferences.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to obtain and review health and vaccination status at the time of admission for a companion pet residing with a resident for 1 of 18 sampled residents (Resident 3). The failed practice created a potential risk for the spread of animal transmitted disease and compromised safety and well-being of other residents and staff.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a urinary bag and tubing were positioned to allow for proper drainage of urine and a physician's order for routine perineal care (the cleaning of the area between the anus and genitals to prevent infections) and a securement device was followed for a resident with an indwelling catheter for 1 of 18 residents (Resident 16). The deficient practice placed the resident at risk for a urinary tract infection (UTI).

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure accurate documentation a protein supplement had been administered without direct observation of the resident's consumption of the protein supplement for 1 of 18 sampled residents (Resident 11). The deficient practice had the potential to compromise the resident's nutritional status and weight.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to obtain physician orders for the insertion of intravenous (IV) lines for 2 of 18 sampled residents (Resident 149 and 150). The failed practice had the potential to result in inappropriate medical treatment and compromised resident safety.

Inspectors wroteBased on observation, interview, document review and record review, the facility failed to ensure resident was free from unnecessary medications. Specifically, a pain medication prescribed for severe pain was administered to 1 of 18 sampled residents (Resident 16) when resident was not experiencing a specific level of pain as ordered by the physician. The deficient practice exposed the resident to potential adverse effects of opioid use, including constipation and narcotic dependence.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure an expired medication for a current resident and medication for a discharged resident was removed from active stock of medications and destroyed or sent back to the pharmacy. The deficient practice put residents at risk of receiving ineffective medications. On 05/16/2025 at 8:20 AM, the South medication room revealed a medication (antibiotic) for a discharged resident in the stock of active medications. There was a medication labeled for a current resident of Daptomycin 400 mg/Normal Saline 100 milliliters (antibiotic) which had a do not use after date of 05/13/2025, mixed in with the active medications. On 05/16/25 at 8:30 AM, the Charge nurse indicated when a resident was discharged , the nurse would be informed by case management of what medications would be going with the resident. [...]

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure nephrostomy care was provided in accordance with physician's order and facility policy for 1 of 4 sampled residents (Resident 2). The deficient practice placed the resident at risk for complications related to the nephrostomy tubes.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) an intravenous (IV) medication bag was labeled with the resident's name for 1 of 4 sampled residents (Resident 4) and 2) the facility's policies on peripheral IV insertion and removal were followed for 1 of 4 sampled residents (Resident 2). The deficient practice placed residents at risk for medication errors and complications related to IV accesses.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure wound care physician orders were being implemented daily for two sampled residents (resident 1 and resident 2). The deficient practice increased the risk of further skin breakdown and infections.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a splint was applied to treat a fractured shoulder as ordered for 1 of 15 sampled residents (Resident 22). The deficient practice may increase the risk of further injury, delayed healing, and potential complications related to the untreated fracture.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure fall interventions and management had been implemented when a resident's risk factors were identified upon admission and categorized as high risk for falls for 1 of 15 sampled residents (Resident 22). The deficient practice could have the potential for further fall incidents and inadequate management of existing fall-related injuries.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure perineal care (process of washing the genitalia and anal area to maintain hygiene and prevent infections) was provided in accordance with facility procedure for a resident with an indwelling catheter and urinary tract infection (UTI) history for 1 of 15 sampled residents (Resident 15). The deficient practice placed the resident at risk for recurrent UTI.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) a resident's baseline weight was obtained upon admission and weekly weights were obtained thereafter for 1 of 15 sampled residents (Resident 168), and 2) a nutritional assessment was completed for residents with significant weight change for 2 of 15 sampled residents (Residents 20 and 16). The deficient practice had the potential for the facility to delay implementing nutritional interventions to prevent weight loss. 1) Resident 168 (R168) R168 was admitted on [DATE] and readmitted on [DATE], with diagnoses including an amputation stump, absence of the right and left legs below the knee. Review of R168's medical record revealed the following recorded weights: -01/30/2024: 114.2 pounds (lbs.) -01/24/2024: 114.0 lbs. [...]

Inspectors wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure 1) the ordered parameters were followed to manage the resident's pain for 1 of 15 sampled residents (Resident 12), and 2) the pain medication was administered prior to wound care treatment for 1 of 15 sampled residents (Resident 20). The deficient practice could have the potential to result in discomfort, and prolonged or unmanaged pain.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure 1 of 15 sampled residents (Resident 60) was free of unnecessary pain medication. The deficient practice had the potential to further the resident's opioid dependency.