A list of the most recent deficiencies for Sage Creek Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-15 | 2023-09-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-11 | 2023-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-06-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-11 | 2023-06-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-11 | 2023-06-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-08-30 | 2022-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-30 | 2022-09-29 | Y |
| Post nurse staffing information every day. | Health | 2022-08-30 | 2022-09-29 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-26 | 2022-06-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-06-27 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-26 | 2022-06-27 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-24 | 2022-04-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-23 | 2022-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-23 | 2022-01-17 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-11-23 | 2022-01-17 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-11-23 | 2022-01-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-23 | 2022-01-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-23 | 2022-01-17 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-11-23 | 2022-01-17 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-23 | 2022-01-17 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Develop a communication plan. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-11-18 | 2022-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-09-17 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-08-04 | 2021-09-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-02 | 2021-07-26 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-21 | 2020-01-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-21 | 2019-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-21 | 2019-12-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-21 | 2019-12-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-21 | 2019-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-21 | 2019-12-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-21 | 2019-12-27 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-11-21 | 2019-12-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-21 | 2019-12-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-21 | 2019-12-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-21 | 2019-12-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-21 | 2019-12-27 | N |
