Inspection Reports for Sage Creek Post-Acute

The facility was found deficient for failing to maintain complete personnel records, specifically lacking evidence of Nevada Automated Background System (NABS) clearance for 2 of 12 employees, placing residents at risk for inappropriate care.

Two complaints (NV00074147 and NV00073845) were investigated and found unsubstantiated with no regulatory deficiencies identified.

The survey included complaint investigations which were unsubstantiated. Deficiencies were identified related to advance directives, companion pet health documentation, catheter care, medication administration, IV line orders, opioid medication administration, and medication storage.

Three complaints were investigated: Complaint #NV00072609 was substantiated with a regulatory deficiency identified; Complaints #NV00072443 and #NV00073417 were not substantiated with no regulatory deficiencies related to the allegations.

The investigation identified one substantiated complaint with a regulatory deficiency related to nephrostomy care and parenteral/IV fluids. Deficiencies included failure to provide nephrostomy care according to physician orders and improper labeling and handling of IV medication bags, placing residents at risk for complications.

Two complaints (#NV00068595 and #NV00069105) were investigated but could not be verified; no regulatory deficiencies were identified related to these complaints.

The investigation found no regulatory deficiencies related to the complaints, which were unverified. However, one unrelated deficiency was identified regarding the improper storage and labeling of drugs and biologicals, specifically that medication carts were unlocked and unattended with normal saline flushes and wound cleanser left on top.

Three complaints were investigated. Complaint #NV00066577 was substantiated regarding a blind resident falling out of bed. Complaint #NV00066472 was substantiated regarding soiled sheets found on the floor. Complaint #NV00066633 was not substantiated.

Three complaints were investigated with two substantiated: a resident who was completely blind fell out of bed, and soiled sheets were found on the floor. Multiple other allegations were not substantiated. Deficiencies were identified related to safe environment and free of accident hazards, including improper handling of soiled linens and failure to implement fall prevention measures.

Two complaints were investigated. Complaint #NV00065967 was substantiated with allegations including failure to follow nothing by mouth orders and failure to provide personal hygiene. Complaint #NV00066060 was substantiated with allegations including failure of staff to wear required PPE.

The investigation substantiated several allegations including issues with resident care such as failure to provide personal hygiene assistance, failure to ensure a resident had nothing by mouth prior to a procedure, and failure to ensure staff wore required PPE. Other allegations were not substantiated. The facility was found to be in compliance with healthcare worker vaccination policies.

Four complaints were investigated: 1) Allegation about insurance coverage was substantiated with no regulatory deficiencies; 2) Allegation of late transportation to dialysis was substantiated; 3) Allegation that call lights were not answered timely was not substantiated; 4) Allegation of a resident left in the middle of care was substantiated with no regulatory deficiencies. Additional allegations included missed showers, linen shortages, call lights at night, repositioning, and staff short staffing, many of which were not substantiated.

Four complaints were investigated with some allegations substantiated and others not substantiated. One regulatory deficiency was identified related to dialysis transportation and scheduling. The facility was found to be 100% compliant with healthcare worker vaccination requirements.

Four complaints and one facility reported incident were investigated. Complaint #NV00064656 was substantiated related to failure to administer a resident's Fentanyl patch per physician's order. Complaint #NV00064624 was substantiated related to discharge to an inappropriate level of care and medication administration issues. Other allegations were not substantiated or had no regulatory deficiencies identified.

The survey found multiple issues including substantiated complaints related to medication administration (Fentanyl patch), discharge planning deficiencies, failure to provide one-to-one feeding assistance, improper management of intravenous lines, failure to administer oxygen as ordered, and lack of timely speech therapy services. The facility also failed to ensure proper medication administration and documentation, including failure to administer a Fentanyl patch as ordered.

Four complaints and one facility reported incident were investigated. Complaint #NV00064656 was substantiated regarding a resident's Fentanyl patch not administered per physician's order. Complaint #NV00064624 was substantiated with a regulatory deficiency for inappropriate discharge to a group home not licensed to provide insulin administration. Other complaints were substantiated with no deficiencies or not substantiated.

The survey included four complaints and one facility reported incident. One complaint regarding a resident's Fentanyl patch not administered per physician's order was substantiated with deficiencies cited. Another complaint about discharge to an inappropriate level of care was substantiated with a regulatory deficiency related to transfer and discharge requirements. Other allegations were substantiated with no regulatory deficiencies or not substantiated. The facility failed to ensure appropriate discharge planning for a resident requiring insulin administration, resulting in discharge to a group home not licensed to provide such care.

The facility failed to develop and maintain facility-specific emergency preparedness policies and procedures, including subsistence needs for staff and patients, evacuation and communication plans, use of volunteers, arrangements with other facilities, contact information for emergency officials, and emergency preparedness training. Documentation was often not facility-specific and staff demonstrated lack of knowledge regarding emergency roles and procedures.

The facility was found deficient in several life safety code areas including means of egress signage, sprinkler system out of service procedures, electrical equipment maintenance, evacuation and fire drills, soiled linen and trash container fire resistance, and electrical equipment testing and maintenance. The facility maintenance director was tasked with corrective actions for each deficiency.

The facility failed to ensure appropriate infection control measures to prevent and/or contain the spread of COVID-19, including improper use of PPE by staff, inadequate N95 fit testing and medical clearance for staff, and failure to offer COVID-19 vaccination to residents and staff.

Four complaints (#NV00063902, #NV00063154, #NV00063754, #NV00063138) were investigated and found not substantiated based on observations, interviews, and record reviews. Allegations included inappropriate discharge, delayed assistance, poor food quality, swelling not addressed, inadequate physical therapy, and staff rudeness.

Three facility-reported incidents related to resident falls were substantiated without regulatory deficiencies. Four complaints investigated were not substantiated based on observations, interviews, and record reviews. One regulatory deficiency was identified related to labeling and storage of drugs and biologicals.

Six facility-reported incidents were investigated. Two allegations of employee to resident abuse could not be substantiated. One injury of unknown origin was substantiated with regulatory deficiency identified. Two resident falls with injury were substantiated. The investigation included interviews with residents, nursing staff, Director of Nursing, DON Consultant, and review of clinical records and facility policies.

Six facility-reported incidents were investigated, with some allegations of abuse and injury substantiated and others not. Regulatory deficiencies unrelated to the reported incidents were identified, including failure to report falls with injuries timely, failure to ensure licensed staff documented medication administration properly, failure to provide timely x-ray services, and failure to administer antibiotics timely.

The facility was found deficient in maintaining clear means of egress, emergency lighting testing and maintenance, cooking facility fire safety, fire alarm system testing and maintenance, fire drills compliance, smoke detector sensitivity testing, and emergency power supply lighting. Corrective actions were planned or implemented for all deficiencies.

The facility was found deficient in multiple areas including failure to provide appropriate bed sizes, develop care plans for wounds, clarify physician orders for restorative services, provide low air loss mattresses for pressure ulcers, complete neurological checks after falls, reweigh residents after significant weight loss, timely change IV dressings, manage pain medications properly, follow dialysis recommendations, and secure medication carts.

The facility failed to develop and implement comprehensive emergency preparedness policies and procedures addressing sheltering in place, use of volunteers and staffing strategies, roles under a waiver declared by the Secretary, communication of occupancy and needs to authorities, and sharing emergency plan information with residents and their representatives. Corrective actions included developing policies, providing staff education, and monitoring compliance.

Complaint #NV00057712 was substantiated regarding medication rooms filled with discontinued medications. Allegations about untreated intravenous lines and understaffing were not substantiated.

The investigation substantiated the allegation that medication rooms contained discontinued medications and expired supplies. Other allegations related to untreated intravenous lines and understaffing were not substantiated. The facility took corrective actions including disposal of expired medications and staff training.

One complaint (#NV00054389) was investigated with allegations of overmedication with antibiotics, improper monitoring leading to falls, and delayed wound treatment. The complaint was not substantiated.

The survey identified regulatory deficiencies related to timely submission of Minimum Data Set (MDS) assessments, baseline care planning, food safety, infection control, and personal food policy. Specific findings included late MDS submissions, lack of baseline care plans for isolation precautions and edema, food safety violations, and failure to follow infection control guidelines during IV antibiotic administration.

The facility was found deficient in emergency preparedness policies and procedures, specifically in tracking the location of on-duty staff during emergencies and sharing emergency plan information with residents and families. Additionally, deficiencies were found in life safety related to cooking facilities and fire extinguishing system maintenance and inspections.

Complaint #NV00053311 was substantiated regarding failure to notify a resident's representative of condition changes, pressure sore precautions, and oxygen administration. Other allegations related to resident care and equipment were not substantiated.

The facility was found to have failed to ensure one resident at risk for pressure ulcers received appropriate care and physician-ordered heel protectors. Several other allegations were not substantiated. The investigation included interviews, record reviews, and observations.

Complaint #NV00051883 was substantiated. The allegation that the facility failed to notify the Nevada State Ombudsman of discharges/transfers was confirmed.

The facility failed to submit written notification of resident transfers and/or discharges to the State Long Term Care Ombudsman's Program as required. Interviews and document reviews confirmed the Case Manager and Director of Nursing were not notifying the Ombudsman of discharges as mandated.

The facility was found to have deficiencies related to compliance with the American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities, specifically failing to install a horizontal surface for personal effects in resident toilet rooms, creating a potential electrical hazard.

The facility was found deficient for failing to ensure that the construction and operating features of the building conformed to the American Institute of Architects (AIA) Guidelines. Specifically, the facility failed to install a horizontal surface for the personal effects of each resident in the resident toilet rooms, which poses an electrical hazard.

The facility was found deficient in meeting NFPA 110 standards for Emergency and Standby Power Systems due to the absence of a remote manual stop station outside the generator housing. Immediate corrective action was taken by installing and testing a remote manual stop button outside the generator housing on October 31, 2017.

The facility failed to meet the National Fire Protection Association (NFPA) 101 Life Safety Code requirements for fire alarm annunciation zoning, specifically failing to install fire alarm annunciation in one of two fire/smoke zones.