Sage Post Acute

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, identified as a high risk for falls, was provided consistently close monitoring/supervision to minimize complications and prevent falls when Resident 1 slipped out of the sling (a mobility aid used to safely move, lift, or reposition an individual with limited physical strength or balance) and fell on the floor during a 2-person mechanical lift (Hoyer Lift, a specialized lifting device used to safely transfer patients between beds, wheelchairs, toilets and/or floor) transfer from bed to wheelchair (w/c). This failure resulted in Resident 1 sustaining a laceration to the left (L) forehead, transferred to the hospital for evaluation, and was found with serious head injuries. 1. [...]

Inspectors wroteBased on interview and record review for two of five sampled residents (Resident 4 and Resident 5), the facility failed to follow their policies and procedures (P&P) for reporting to appropriate agencies a verbal altercation, on 6/9/26 between Resident 4 and Resident 5. This failure to report promptly resulted in:1. No documentation reporting a verbal altercation between Resident 4 and Resident 5 to Law Enforcement within the required regulatory timeframe.2. Potential to negatively impact the protection of all 85 facility residents from abuse. A review of Resident 4's admission Record indicated Resident 4 was readmitted to the facility in 2025 with diagnoses that included dementia (memory loss; a group of thinking and social symptoms that interferes with daily functioning) and hearing loss. [...]

Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 2), the facility failed to ensure Resident 2, identified as a high risk for falls, was provided consistently with close monitoring/supervision and comprehensive care plan interventions to address Resident 2's nursing and safety needs were implemented, to minimize complications and prevent falls when Resident 2 had an unwitnessed fall inside Resident 2's room. This failure negatively impacted Resident 2's quality of care and services received resulting in Resident 2 being transferred to the emergency department (ED) for evaluation and found with fracture of surgical neck with greater tuberosity extension (a bony facture that travels into the large bump at the top of the upper arm bone). [...]

Inspectors wroteBased on observation, interview and records review the facility failed to supervise one of three sampled residents (Resident 1), when Resident 1 was left unsupervised and unattended in a shower chair in her room. This deficient practice resulted in Resident 1 falling out of shower chair, sustaining L5 (5th lumbar- lower back bone) compression fracture (broken bone due to a collapse). During a review of Resident 1' admission Record (record that contains biographical information) printed on 5/11/26, indicated Resident 1 was admitted to the facility in March 2016, with multiple diagnosis including muscle weakness, dementia (decline in cognitive function), osteoarthritis of knees (chronic degenerative joint disease). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure presents a threat to residents reaching their highest practicable level of well-being and had the potential to endanger the health and safety of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for six out of 24 final sampled residents (Residents 7,11,16,26,28 and 37). This had potential for the facility to provide treatment and services against the residents' wishes.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure Medications are accurately and safely acquired, received, dispensed, stored, and administered for two of four Residents, Resident 16 and Resident 28 during medication administration, not following their facility's policy and procedure and standards of practice:1. When Licensed nurse left Resident 16s medications (1 tab of Ferrous sulfate [to prevent and treat low iron anemia] 325 milligrams (mg) and 1 tablet of multivitamin) unattended on top the medication cart when administering medication to Resident 16. 2. When Licensed Nurse left Resident 28's medications (1 tablet of Aspirin [used to treat mild pain, arthritis, it also lowers the risk of heart attack, stroke, or blood clot] 81 mg chewable) unattended on top of the medication cart. [...]

Inspectors wroteBased on Observation, interviews, and Record Reviews the facility failed to ensure Medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with: the prescriber's order; manufacturer's specifications (not recommendations) or accepted professional standards and principles which apply to professionals providing services) rates are 5 percent or lesser for three out of five residents (Resident 1, 16, and 68) during medication administration:1. When Licensed Nurse administered Alendronate medication (a medication used to prevent and treat osteoporosis [a condition in which the bones become thin and weak and break easily] in men and women) for Resident 16, was Administered to resident 16, not following Physicians orders or medication bubble pack labeling instructions and professional standards of practice.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were served palatable, flavorful food and properly cooked vegetables. This deficient practice placed the residents at risk of decreased nutrient intake possibly leading to weight loss and/or nutritional medical complications who received food from the kitchen.1. During observation on 8/13/25 at 12:47 p.m., in the facility conference room, two test trays containing one regular and another puree (blending or mashing regular food into a smooth, pudding-like consistency, eliminating lumps and making it easier to swallow) were presented. 2. During a concurrent observation and interview on 8/13/25 at 12:47 p.m with the Assistant Dietary Manager (ASDM) and Dietary Manager (DM) a regular and puree texture meal was sampled immediately following the delivery of the last resident tray. [...]

Inspectors wroteBased on interview, record review and observation, the facility did not ensure that food was stored, prepared, and served in a safe and sanitary manner when the following was noted:1. Food preparation utensils and equipment were not cleaned and/or maintained in good condition.2. A 2 slice and conveyor toaster were not maintained in clean condition.3. One knife blade tip was bent.4. Microwave has brown stain and chipped turntable.5. Cup/Food container lids was in drawer without original packaging.6. An industrial can opener was not maintained in clean condition.7. Tray line pans and sheet pans were not air dried and were stacked wet.8. Pots and pans were not air dried and stacked wet.10. The oven was not maintained in clean condition.11. Nine expired food items. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program when the laundry department did not have a separate space for clean and unclean hampers. This failure placed the residents at increased rate of healthcare- associated infections.

Inspectors wroteBased on record review and interviews, the facility failed to ensure Resident 51's wallet was protected from loss. This deficient practice had the potential to result in Resident 51 not having access to their items in their wallet and/or feelings of living in a safe, homelike environment. During a review of Resident 51's admission Record, dated 8/14/25, indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses that included cachexia (weakness of the body due to severe chronic illness), hypokalemia (low potassium), dysphagia (trouble swallowing) and acute kidney failure (kidney don't work) and that he was his own responsible party. During a review of Resident 51's Inventory List, dated 5/3/25, the Inventory List indicated, Resident 51 had 1 wallet listed among the items. During an interview on 8/12/25 at 10:55 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of individuals representing different departments of the facility) initiated a care conference meeting for one of 24 sampled residents for seven months. As a result, Resident 69's responsible party was not able to participate in planning his care.

Inspectors wroteBased on observation and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents in 6 (Rooms 5, 23, 26, 28, 29, and 30) of 45 resident rooms in the facility. The failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) with impaired mental status received adequate supervision to prevent accident hazards when Resident 1 left the facility and was found and brought to the police station by a concerned citizen. This failure resulted in Resident 1's elopement (elopement is when a patient or resident who is incapable of adequately protecting themselves, departs the health care facility unsupervised and undetected) and had the potential for Resident 1 to be dehydrated, injured, or struck by a motor vehicle.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure narcotic medications were signed out according to professional standards for 1 (Resident #209) of 2 sampled residents reviewed for pain management and failed to ensure narcotic reconciliation counts were completed for 1 of 1 medication room and 1 of 2 medication carts.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure enhanced barrier precautions (EBP) were implemented and catheter collection bags were kept off the floor for 3 (Residents #13, #5, and #50) of 3 sampled residents with indwelling urinary catheters.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. Specifically, the facility failed to accurately code the presence of an indwelling urinary catheter for 1 (Resident #5) of 3 sampled residents who had urinary catheters and failed to accurately code the use of an antiplatelet medication for 1 (Resident #19) of 1 resident reviewed for MDS discrepancies. Findings Included: 1. The CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, dated October 2023, SECTION H: BLADDER AND BOWEL, revealed, Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete a baseline care plan within 48 hours of admission for 1 (Resident #207) of 3 residents reviewed for baseline care plans.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of anticoagulant medications for 1 (Resident #47) of 5 sampled residents reviewed for unnecessary medications and failed to develop a care plan addressing urinary catheters for 2 (Resident #13 and Resident #50) of 3 sampled residents with indwelling urinary catheters.

Inspectors wrote2. An admission Record revealed the facility originally admitted Resident #13 on 04/12/2024 and readmitted the resident on 04/23/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident did not have an indwelling urinary catheter at the time of the assessment. Resident #13's care plan revealed a Focus area, initiated on 04/13/2024, that indicated the resident had bowel and bladder incontinence. The care plan did not address the presence of an indwelling urinary catheter. A hospital Discharge Summary, dated 04/23/2024, revealed the resident had renal failure and was being discharged from the hospital to a skilled nursing facility with hospice services. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #47) of 5 sampled residents reviewed for unnecessary medications was monitored for potential side effects related to the use of a prescribed anticoagulant medication.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). The facility had 3 medication errors out of 32 total opportunities, resulting in a medication error rate of 9.38%, affecting 2 (Resident #15 and Resident #21) of 5 residents observed during medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #21) of 5 residents observed during medication administration was free of a significant medication error. Specifically, the facility failed to administer metoprolol to Resident #21.

Inspectors wroteBased record review, interview, and facility document and policy review, the facility failed to ensure nursing staff documented the administration of as needed (PRN) pain medication for 1 (Resident #209) of 2 sampled residents reviewed for pain management.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure multiple-resident bedrooms measured at least 80 square (sq) feet (ft) per resident in 6 (Rooms 5, 23, 26, 28, 29, and 30) of 45 resident rooms in the facility. There were no negative consequences attributable to the decreased space in the six rooms; nor were any safety concerns noted. Recommend granting of room waiver.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain supervision for one (Resident 12) to ensure the safety of all residents. Resident 12 had a history of striking out at other residents and staff. This failure resulted in an unsafe environment for all residents due to a lack of continued supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices safety for 51 of 51 residents who were residing at the facility. Multiple items were found in the kitchen that were not dated or had expired. This deficient practice had the potential health risk of foodborne illness because of their compromised health status.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 46) of 17 sampled residents, the facility allowed Resident 46 to self-administer medication without a physician's order or assessment of the resident's ability to self-administer medications safely. This failure has the potential for Resident 46 to not take the medications as prescribed.

Inspectors wroteBased on observation and interview, the skilled nursing facility's staff did not maintain an environment free from abuse for two, Residents 9 and 353 of 17 sampled residents. Resident 353 and 9 were engaged in verbal abuse and not separated by staff as soon as possible. This failure resulted in unnecessary verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the ombudsman (an official appointed to advocate and investigate resident complaints) was notified before discharging one (Resident 52) of three sampled residents from the facility. This deficient practice had the potential to deny protection and advocacy rights from the Ombudsman on behalf of Resident 52 from a possible inappropriate discharge or explore other available options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff consistently used available methods to communicate with Resident 36. The certified nursing assistant 1 (CNA 1) did not know the resident's primary language (Russian) and spoke Spanish to Resident 36. For Resident 10, staff failed to assist in positioning the resident appropriately for eating breakfast. These failures resulted in staff not communicating in Resident 36's preferred language with the use of a communication board (symbols in primary language) to enable Resident 36 to communicate needs. Resident 10 ate his breakfast at a 30 degree lying position which did not promote digestion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal hygiene assistance for two (Residents 2 and 3) of 17 sampled residents. Residents 2 and 3 had long, chipped and dirty fingernails containing a black substance underneath the nails. This failure had the potential for the development of infection and /or skin injuries for Residents 2 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for one (Resident 2) of 17 sampled residents when Resident 2 did not have interventions in place to prevent the loss of function/mobility of Resident 2's right hand. This failure had the potential for Resident 2's contractures (a condition of shortening and hardening of muscles, tendons or other tissues, often leading to deformity and rigidity of joints) to worsen.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one resident (Resident 23) was seen at least once, every 60 days by the physician. The Attending Physician (MD) did not personally conduct alternate visits with Resident 23 as required. This failure had the potential for inadequate medical care and treatment when the physician did not evaluate Resident 23.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to identify expired narcotics (medications used to relieve pain) in the e-kit (emergency kit: a locked box which contains a limited supply of medications for the facility to use during emergency situations, and after pharmacy hours). This failure had the potential for residents to experience inadequate pain control.

Inspectors wroteBased on interview and record review, the facility failed to maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and prevent or minimize adverse consequences related to medication therapy, for three of three sampled residents, (Resident 30, Resident 37 and Resident 3) when the facility did not inform the physicians about the pharmacist's recommendation of changing the medication dosages for Resident 30. The drug regimen review was not done within 30-days by the licensed pharmacist for Residents 3 and 37. These failures had the potential to receive unnecessary medication for Resident 30. For Resident 37 and Resident 3, this had the potential of adverse side effects of the medications.

Inspectors wroteBased on interview and record review, for one (Resident 37) of 17 sampled residents, the facility failed to accurately monitor, document, and communicate the effects of anti-psychotic (Seroquel) medication therapy. This failure had the potential for adverse side effects of Seroquel and possible need to adjust the medication dosage.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 46) of 17 sampled residents was free of significant medication error when Licensed Staff administered Omeprazole (reduces the amount of acid in the stomach) after the medication was discontinued. This failure had the potential for Resident 46 to be exposed to more side effects from taking the medication longer than expected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly after they have been discontinued. This failure had the potential of exposing residents to drugs and biologicals with questionable potency and efficacy. 1. Two Glucagon (medication for low blood sugar) kits were found at the bottom drawer of the refrigerator in the medication room. 2. The refrigerator freezer in Station 2's medication room had a thick layer of frost. 3. Narcotic medications that were discontinued were kept stored in Medication Cart B.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain the infection control program. The Restorative Nursing Assistant (RNA-trained to assist residents with strengthening muscles and range of motion) entered an isolation room without wearing personal protective equipment (PPE) and performing hand hygiene. For Resident 10, a half-filled urinal containing yellow urine was not removed from the meal tray while Resident 10 ate breakfast. These failures had the potential to result in the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet per resident in room [ROOM NUMBER] that was occupied by two residents. This failure had the potential to result in a lack of sufficient space for providing care and storage of resident belongings.