Inspection Report Summary
The most recent inspection on June 26, 2025, found no deficiencies related to the complaint investigated. Prior inspections showed a pattern of deficiencies mainly involving resident care issues such as fall interventions, wound care, and staff communication, as well as Life Safety Code violations including fire safety equipment maintenance. Complaint investigations included substantiated cases of physical abuse, failure to provide trauma-informed care, and inadequate follow-up on background checks, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaint investigations were unsubstantiated, and the facility generally corrected cited deficiencies promptly. The trend suggests some improvement in recent months, with the latest inspections showing no deficiencies after earlier findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
42 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Jun 26, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461845.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00461845 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 33
Census Bed Type - SNF: 9
Census Total: 42
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 10
Census Payor Type - Total: 42
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 2, 2025
Visit Reason
Paper compliance review of the Investigation of Complaints IN00459121 completed on May 22, 2025.
Findings
Sage Bluff Health and Rehab Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation IN00459121.
Complaint Details
Complaint IN00459121 was investigated and corrected.
Report Facts
Complaint ID: 459121
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
May 21, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457991, IN00458919, and IN00459121 at Sage Bluff Health & Rehab Center.
Findings
No deficiencies were cited related to complaints IN00457991 and IN00458919. Deficiencies related to complaint IN00459121 were cited involving failure to ensure fall interventions were followed for one resident (Resident B), who fell during an outside appointment without staff accompaniment as required.
Complaint Details
Complaint IN00459121 was substantiated with deficiencies cited related to fall interventions for Resident B. Complaints IN00457991 and IN00458919 had no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure fall interventions were followed for Resident B, who fell during an outside appointment and was not accompanied by staff as required. | SS=D |
Report Facts
Census: 47
SNF/NF beds: 11
SNF beds: 36
Medicare residents: 9
Medicaid residents: 27
Other residents: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Provided incident report and interviewed regarding fall incident and facility practices |
| Maintenance Director | Transported Resident B to appointments and interviewed about accompaniment practices | |
| Licensed Practical Nurse 3 | LPN | Interviewed regarding fall interventions and supervision of residents during appointments |
| Licensed Practical Nurse 4 | LPN | Interviewed regarding fall interventions and supervision of Resident B |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 22, 2025
Visit Reason
Paper compliance review of the Investigation of Complaints IN00455256 and IN00455764.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations. Both complaints IN00455256 and IN00455764 were corrected.
Complaint Details
The visit was related to complaint investigations IN00455256 and IN00455764, both of which were corrected.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 2
Mar 23, 2025
Visit Reason
This visit was for the investigation of four complaints (IN00454853, IN00455256, IN00455764, and IN00455806) regarding the facility.
Findings
The facility was found deficient related to two complaints: one involving condescending remarks by a staff member towards a resident, and another involving failure to provide wound care to a resident with a stage 4 pressure ulcer. Two complaints had no deficiencies cited.
Complaint Details
Complaint IN00454853 and IN00455806 had no deficiencies related to the allegations. Complaint IN00455256 was substantiated with deficiencies related to condescending remarks by QMA 8. Complaint IN00455764 was substantiated with deficiencies related to failure to provide wound care to Resident D.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 residents reviewed were free from condescending remarks by QMA 8 towards Resident C. | SS=D |
| Facility failed to ensure wound care was provided to 1 of 3 residents reviewed (Resident D) with a stage 4 sacral pressure ulcer. | SS=D |
Report Facts
Census: 56
Total Capacity: 56
Medicare Residents: 4
Medicaid Residents: 34
Other Residents: 18
Brief Interview for Mental Status (BIMS) score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Signed the report as facility administrator |
| Qualified Medical Assistant 8 (QMA 8) | Named in condescending remarks and verbal abuse findings related to Resident C |
Inspection Report
Re-Inspection
Census: 49
Capacity: 84
Deficiencies: 0
Jan 30, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/04/24 was performed to verify compliance with previous deficiencies.
Findings
The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, LSC, Chapter 19, Existing Health Care Occupancies. The facility is fully sprinkled except for a small storage shed.
Report Facts
Facility capacity: 84
Census: 49
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Dec 13, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447887.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00447887 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 48
Census Bed Type - SNF/NF: 38
Census Bed Type - SNF: 10
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 33
Census Payor Type - Other: 9
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 4, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Sage Bluff Health and Rehab Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 50
Capacity: 84
Deficiencies: 3
Dec 4, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to replace or test dry pendant sprinklers older than ten years, failure to inspect and maintain fire damper systems on schedule, and failure to complete annual inspections and testing of fire door assemblies.
Severity Breakdown
SS=E: 1
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 2 dry pendant sprinklers in the cooler older than ten years were replaced or tested in accordance with NFPA 25. | SS=E |
| Failed to ensure 1 of 1 fire damper systems were inspected and maintained after the first year and at least every four years as required by NFPA 90A. | SS=F |
| Failed to ensure annual inspections and testing of 6 of 6 fire door assemblies were completed in accordance with NFPA 80 and Life Safety Code. | SS=F |
Report Facts
Facility capacity: 84
Census: 50
Dry pendant sprinklers: 2
Fire damper systems: 1
Fire door assemblies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Interviewed regarding sprinkler, damper, and fire door inspection deficiencies |
Inspection Report
Renewal
Census: 46
Capacity: 46
Deficiencies: 4
Nov 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00444425.
Findings
The facility was found deficient in timely reporting of an elopement incident, ensuring non-pharmacological interventions before administering PRN pain medication, communication with the dialysis center, and managing resident behaviors. Complaint allegations were not substantiated. Corrective actions and audits were planned for each deficiency.
Complaint Details
Complaint IN00444425 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to report elopement in a timely manner for 1 of 1 residents reviewed (Resident 199). | SS=D |
| Failed to ensure non-pharmacological interventions were attempted before administering PRN pain medication for 1 of 2 residents reviewed (Resident 5). | SS=D |
| Failed to ensure communication with dialysis center for 1 of 2 patients reviewed (Resident 30). | SS=D |
| Failed to manage behaviors for 1 of 8 residents reviewed (Resident 40). | SS=D |
Report Facts
Census: 46
Total Capacity: 46
PRN pain medication administration dates: 15
Behavior incidents observed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Named in relation to the elopement incident and report |
| LPN 4 | Licensed Practical Nurse | Observed during behavior incidents involving Residents 14 and 40 and provided redirection |
| Director of Nursing | Director of Nursing | Interviewed regarding pain management, dialysis communication, and behavior management findings |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Educated Administrator and Director of Nursing on reporting requirements |
| Social Worker | Social Worker | Responsible for reviewing residents with behaviors and completing audits |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding dialysis communication and behavior management |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 8, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00436741 and IN00439118 completed on July 23, 2024.
Findings
The facility, Sage Bluff Health and Rehab Center, was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00436741 and IN00439118, with the facility found in compliance based on paper review.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Jul 23, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00438417 and IN00439226 related to allegations of abuse and trauma-informed care.
Findings
The facility failed to protect a resident from physical abuse by staff and failed to report the abuse timely. The abusive staff member was terminated, and corrective actions were implemented. Additionally, the facility failed to provide trauma-informed care by not identifying triggers or implementing resident-specific approaches for a trauma survivor. The facility updated care plans and policies to address these issues.
Complaint Details
Complaint IN00438417 involved physical abuse and failure to report abuse timely. Complaint IN00439226 involved failure to provide trauma-informed care. Both complaints were substantiated with past non-compliance corrected prior to the survey.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect a resident's right to be free from physical abuse by staff. | SS=D |
| Failed to report timely physical abuse of a resident. | SS=D |
| Failed to ensure trauma-informed care by identifying triggers and implementing resident-specific approaches. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 39
Census Bed Type - SNF: 9
Total Census: 48
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee 2 | Witnessed abuse, failed to report immediately, later reported incident to Administrator. | |
| Employee 3 | Assisted in repositioning resident during abuse incident, suspended for failure to report. | |
| Employee 5 | Struck resident in the face, suspended and terminated for abuse. | |
| Isaac Lenon | Administrator | Facility Administrator involved in investigation and interviews. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Apr 3, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00430994, IN00430998, IN00431004, IN00431014, IN00431018, IN00431190, and IN00431182).
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaints IN00430994, IN00430998, IN00431004, IN00431014, IN00431018, IN00431190, and IN00431182 found no deficiencies related to the allegations.
Report Facts
Census: 49
Total Capacity: 49
Census Bed Type - SNF/NF: 36
Census Bed Type - SNF: 13
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 33
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Mar 19, 2024
Visit Reason
This visit was conducted to investigate multiple complaints identified as IN00427791, IN00429580, IN00429620, IN00430180, IN00430186, and IN00430194.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaints IN00427791, IN00429580, IN00429620, IN00430180, IN00430186, IN00430194 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 51
Census Bed Type - SNF/NF: 39
Census Bed Type - SNF: 12
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 34
Census Payor Type - Other: 10
Inspection Report
Re-Inspection
Census: 49
Capacity: 84
Deficiencies: 0
Feb 13, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/03/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety From Fire, and the 2012 Edition of the NFPA 101 Life Safety Code. The building is fully sprinkled except for a small storage shed, and fire alarm and smoke detection systems are in place.
Report Facts
Facility capacity: 84
Census: 49
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426834.
Findings
No deficiencies related to the allegations in Complaint IN00426834 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00426834 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 54
Census SNF/NF beds: 38
Census SNF beds: 16
Census Medicare residents: 11
Census Medicaid residents: 34
Census Other residents: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 24, 2024
Visit Reason
The document is a paper compliance review related to the investigation of complaints IN00423851 and IN00424136 completed on January 5, 2024.
Findings
Sage Bluff Nursing and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigations.
Complaint Details
The visit was related to complaint investigations IN00423851 and IN00424136. The facility was found to be in compliance.
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 8, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey conducted on December 11, 2024.
Findings
Sage Bluff Health and Rehab Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Jan 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00423851, IN00424136, IN00424470, and IN00424494 at Sage Bluff Health & Rehab Center.
Findings
The facility was found deficient in ensuring a fall assessment was completed after a witnessed fall for one resident and failed to document meal consumption percentages and monthly weights for several residents. Some complaints had related deficiencies cited, while others had no deficiencies.
Complaint Details
Complaint IN00423851 had federal/state deficiencies cited related to allegations at F692. Complaint IN00424136 had federal/state deficiencies cited related to allegations at F689. Complaints IN00424470 and IN00424494 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a fall assessment was completed after a witnessed fall for 1 of 3 residents reviewed (Resident C). | SS=D |
| Failed to ensure meal consumption percentages were documented for 3 of 3 residents reviewed (Residents D, E, F) and monthly weights were documented for 2 of 3 residents reviewed (Residents D, E). | SS=D |
Report Facts
Census: 46
SNF/NF beds: 34
SNF beds: 12
Medicare residents: 10
Medicaid residents: 27
Other residents: 9
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Signed report as facility representative |
| Darnella Williams | LPN | Obtained weights for Residents D, E, and F |
| CNA 3 | Involved in Resident C fall incident and reporting | |
| CNA 2 | Notified nurse of Resident C's fall injuries | |
| Nurse 7 | Notified of Resident C's fall by CNA 2 | |
| QMA 4 | Qualified Medication Aide | Assisted with Resident C after fall but did not report fall |
| CNA 6 | Provided information on meal consumption and weight documentation | |
| RN 5 | Registered Nurse | Provided information on fall assessment and meal/weight documentation |
| Interim Director of Nursing | Interim DON | Provided investigation file and interviews regarding Resident C fall and nutrition documentation |
Inspection Report
Life Safety
Census: 46
Capacity: 84
Deficiencies: 7
Jan 3, 2024
Visit Reason
A Life Safety Code (LSC) Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure of a horizontal exit fire door to automatically close and latch, incomplete fire watch plan for fire alarm system outages, incomplete sprinkler system testing and maintenance documentation, improper use of extension cords, missing oxygen storage warning signage, and lack of staff training on oxygen transfilling procedures.
Severity Breakdown
SS=E: 4
SS=C: 2
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 horizontal exit fire door sets were arranged to automatically close and latch. | SS=E |
| Failed to provide a complete written fire watch policy for fire alarm system outages over 4 hours. | SS=C |
| Failed to ensure sprinkler system completed all required testing including internal pipe inspection, backflow preventer testing, and quarterly inspections. | SS=F |
| Failed to provide correct written policies for sprinkler system impairment and fire watch for outages over 10 hours. | SS=C |
| Failed to ensure flexible cords were not used as a substitute for fixed wiring; extension cord used for refrigerator power supply. | SS=E |
| Failed to ensure oxygen storage room door had a precautionary sign indicating oxidizing gases stored within. | SS=E |
| Failed to ensure staff was properly trained on oxygen transfilling procedures in oxygen storage room. | SS=E |
Report Facts
Facility capacity: 84
Census: 46
Deficiencies cited: 7
Completion dates: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Named in relation to findings and exit conference |
Inspection Report
Annual Inspection
Census: 46
Capacity: 46
Deficiencies: 3
Dec 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from December 5 to December 11, 2023.
Findings
The facility was found deficient in sufficient nursing staff to prevent intrusive behaviors affecting multiple residents, and failed to post accurate daily nurse staffing information. Resident 147 exhibited intrusive and disruptive behaviors that were not effectively managed due to inadequate staffing and incomplete person-centered care plans. The facility also failed to maintain timely and accurate nurse staffing postings accessible to residents and visitors.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to schedule sufficient nursing staff to prevent intrusive behavior affecting 7 of 22 residents reviewed, including Resident 147 who exhibited loud vocalizations and intrusive wandering. | SS=E |
| The facility failed to ensure the daily report of nursing staff directly responsible for resident care was accurately posted during 2 of 3 observations. | SS=D |
| The facility failed to implement person-centered interventions to prevent intrusive behaviors for Resident 147, who exhibited disruptive vocalizations and wandering, and whose care plan was not person-centered or adequately detailed. | SS=D |
Report Facts
Survey dates: 5
Census: 46
Total capacity: 46
Residents affected by intrusive behavior: 7
BIMS scores: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Signed the inspection report |
| LPN 6 | Licensed Practical Nurse | Reported residents afraid of Resident 147 and staffing challenges on third shift |
| CNA 5 | Certified Nursing Aid | Observed calming Resident 147 and noted dementia diagnosis was incorrect |
| LPN 8 | Licensed Practical Nurse | Indicated care plan for Resident 147 was not updated properly |
| SSD | Social Services Director | Created baseline care plan for Resident 147 and participated in interviews |
| DON | Director of Nursing | Discussed staffing and care plan issues for Resident 147 |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Jun 15, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409836.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00409836 - No deficiencies related to the allegations are cited.
Report Facts
Census: 44
Census Bed Type - SNF/NF: 30
Census Bed Type - SNF: 14
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 14
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
May 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407700.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00407700 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 48
SNF/NF beds: 34
SNF beds: 14
Medicare residents: 3
Medicaid residents: 29
Other payor residents: 16
Inspection Report
Re-Inspection
Census: 50
Capacity: 84
Deficiencies: 0
Apr 19, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/30/23 and the first PSR on 04/04/23 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Sage Bluff Health and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety From Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, LSC, Chapter 19, Existing Health Care Occupancies. The facility was fully sprinkled except for a small storage shed.
Inspection Report
Re-Inspection
Census: 48
Capacity: 84
Deficiencies: 1
Apr 4, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 01/30/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to a missing handrail on an exit discharge ramp. The handrails were installed and the work was completed on April 7, 2023.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 exit discharge ramp was equipped with handrails as required by LSC Section 7.2.5.4.1. This deficient practice could affect 25 residents evacuated from the 400-hall. | SS=E |
Report Facts
Facility capacity: 84
Census: 48
Ramp length: 35
Residents affected: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Rees | Executive Director | Signed the report |
| Environmental Services Director | Interviewed regarding the missing handrails on the exit discharge ramp | |
| Administrator | Interviewed and provided statements about the handrail installation delay |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 1, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 1, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00400977 completed on February 13, 2023.
Findings
Sag Bluff Health and Rehab Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00400977 completed on February 13, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Feb 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400977, which was substantiated with deficiencies related to the allegations cited at F689.
Findings
The facility failed to ensure the front door alarm was loud enough to be heard in resident care areas, resulting in a resident (Resident B) exiting the facility unsupervised. Resident B was found outside in a wheelchair, combative and resistant to return. The facility implemented 1:1 monitoring, installed new louder alarms, educated staff on elopement policy, and conducted elopement drills.
Complaint Details
Complaint IN00400977 was substantiated. The investigation found that the alarm was not audible enough in resident care areas, contributing to the resident elopement incident.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the door alarm sounded loud enough to be heard in resident care areas to prevent a resident from exiting outside of the facility. | SS=D |
Report Facts
Census: 50
Residents with wanderguards: 1
Ativan dosage: 1
Monitoring duration: 3
Elopement drills frequency: 4
Elopement drills frequency: 6
Inspection Report
Routine
Census: 54
Capacity: 84
Deficiencies: 25
Jan 30, 2023
Visit Reason
A routine Life Safety Code and Emergency Preparedness inspection survey was conducted to assess compliance with federal and state regulations.
Findings
The facility was found not in compliance with multiple Life Safety Code and Emergency Preparedness requirements including emergency preparedness plan maintenance, emergency power system testing, fire alarm system maintenance, sprinkler system maintenance, fire door inspections, smoking policy enforcement, and safe oxygen cylinder storage and transfilling procedures.
Severity Breakdown
Level B: 2
Level C: 4
Level D: 1
Level E: 7
Level F: 9
Deficiencies (25)
| Description | Severity |
|---|---|
| Failed to properly maintain the Emergency Preparedness Plan including contact information and policies. | Level C |
| Failed to conduct required emergency preparedness exercises twice per year. | Level F |
| Generator lacked required monthly load testing and weekly inspection. | Level F |
| Main entrance exit door code was incorrect, preventing immediate egress. | Level B |
| Two hazardous area enclosure doors were held open and not self-closing. | Level E |
| Exit discharge ramp lacked required handrails. | Level E |
| Two storage rooms were not protected as hazardous areas due to non-self-closing doors. | Level E |
| Fire alarm system had a smoke detector installed too close to an air supply vent. | Level E |
| Fire alarm system semi-annual visual inspections were incomplete and fire panel time was incorrect. | Level F |
| Fire alarm system out of service policy was incomplete and lacked required contact information. | Level C |
| Sprinkler system supervisory attachments were not electronically monitored. | Level F |
| Sprinkler system inspections and testing were incomplete or undocumented. | Level F |
| Fire watch policy was incomplete and lacked required contact information. | Level C |
| Two resident room corridor doors did not latch properly. | Level D |
| Three fuel fired water heaters lacked current inspection certificates. | Level E |
| Fire safety plan did not address locations of smoke/fire barriers. | Level C |
| Fire drills were not conducted or documented on all shifts quarterly. | Level F |
| Smoking policy enforcement failed; staff were observed smoking on facility grounds. | Level E |
| Annual inspection and testing of seven fire door assemblies were not completed. | Level F |
| Portable space heater policy was inadequate and a space heater was used without proper labeling or inspection. | Level E |
| Non-hospital grade electrical receptacles in resident rooms were not tested annually. | Level F |
| Emergency generator testing and documentation were incomplete or missing. | Level F |
| Extension cords and power strips were improperly used to supply high current draw equipment. | Level E |
| Oxygen cylinders were not properly segregated between full and empty tanks. | Level B |
| Staff were not properly trained on liquid oxygen transfilling procedures and no safe practices policy was in place. | Level E |
Report Facts
Facility capacity: 84
Census: 54
Fire door assemblies: 7
Resident rooms: 70
Fire drills missing: 4
Fuel fired water heaters: 3
Fire door inspections overdue: 7
Fire door assemblies: 6
Fire door assemblies: 1
Oxygen cylinders: 2
Fire door inspections completed: 7
Fire alarm semi-annual inspection: 1
Generator load testing missing months: 5
Generator weekly inspections missing months: 5
Battery powered generator task lighting testing missing months: 5
Dry system trip test overdue: 1
Dry system air leakage test overdue: 1
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 3
Jan 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00398528.
Findings
The facility was found to have deficiencies related to dialysis communication and psychotropic medication use. Complaint IN00398528 was unsubstantiated with no deficiencies related to the allegations. The facility failed to ensure ongoing communication with the dialysis facility for one resident and failed to ensure appropriate diagnoses for psychotropic medications for two residents. The facility also failed to maintain an effective QAPI program to identify and correct quality deficiencies.
Complaint Details
Complaint IN00398528 was investigated and found to be unsubstantiated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 2 residents reviewed (Resident 142). | SS=D |
| Failed to ensure medication prescribed had appropriate diagnoses identified for 2 of 5 residents reviewed (Resident 39 and Resident 142). | SS=D |
| Failed to ensure a process was in place to identify and correct quality deficiencies for 1 of 1 review related to QAPI program. | SS=D |
Report Facts
Census: 46
Survey dates: January 11, 12, 13 and 17, 2023
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Interviewed regarding dialysis communication and assessments for Resident 142 |
| Director of Nursing | Director of Nursing | Reviewed affected residents and responsible for education and audits related to dialysis communication and psychotropic medication use |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided policy information and interviews related to dialysis communication and psychotropic medication use |
| NP | Nurse Practitioner | Reviewed and updated diagnoses and medication orders for Residents 39 and 142 |
| Administrator | Administrator | Provided information about QAPI committee and facility processes |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Oct 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00389886.
Findings
The complaint IN00389886 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00389886 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census: 45
Census Bed Type - SNF/NF: 31
Census Bed Type - SNF: 14
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Aug 1, 2022
Visit Reason
This visit was for the investigation of multiple complaints (IN00384697, IN00385819, IN00386145, IN00386601, and IN00387097) and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found to have failed to follow up on inconclusive criminal background checks for 8 of 15 employees reviewed, which is a violation of abuse/neglect policies. Some complaints were substantiated with related deficiencies cited, while others were unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00384697 was substantiated with federal/state deficiencies cited at F607. Complaints IN00385819, IN00386145, and IN00387097 were unsubstantiated due to lack of evidence. Complaint IN00386601 was substantiated but no deficiencies related to the allegations were cited.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to follow up on inconclusive criminal background checks for 8 of 15 employees reviewed. | SS=E |
Report Facts
Number of employees with inconclusive background checks: 8
Census: 42
Survey dates: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2022
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint Survey IN00384697 completed on August 1, 2022.
Findings
Sage Bluff Health and Rehab Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint Survey IN00384697 completed on August 1, 2022; facility found in compliance.
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