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Deficiency Records for Sage Bluff Health and Rehab Center
A list of the most recent deficiencies for Sage Bluff Health and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Sage Bluff Health and Rehab Center. 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? |
|---|---|---|---|---|
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-07-23 | 2024-08-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-23 | 2024-07-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-23 | 2024-07-11 | Y |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2024-01-03 | 2024-02-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-01-03 | 2024-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-03 | 2024-02-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-03 | 2024-02-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-03 | 2024-02-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-03 | 2024-02-04 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2024-01-03 | 2024-02-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-05 | 2024-01-24 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-05 | 2024-01-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-11 | 2024-01-05 | N |
| Post nurse staffing information every day. | Health | 2023-12-11 | 2024-01-05 | N |
| Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. | Health | 2023-12-11 | 2024-01-05 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2023-01-30 | 2023-04-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-01-30 | 2023-03-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-13 | 2023-02-28 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-17 | 2023-02-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-17 | 2023-02-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-17 | 2023-02-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-04 | 2022-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-27 | 2022-05-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-06 | 2022-04-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-06 | 2022-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-06 | 2022-04-26 | Y |
| 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 | 2022-04-06 | 2022-04-26 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-06 | 2022-04-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Develop a communication plan. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-16 | 2022-03-11 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-10 | 2022-01-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-12-10 | 2022-01-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-10 | 2022-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-10 | 2022-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-10 | 2022-01-10 | N |
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