Sage View Care Center

Based on staff schedule review, daily staff posting review, time punch history review, and staff interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day, 7 days per week. The census was 533. The findings were: 1. Review of the February 2025 nursing schedule failed to show an RN had been scheduled for 2/8/25. 2. Review of the daily staff postings failed to show there was an RN on duty for 2/8/25. 3. Review of the time punch history for RN #1 showed on 2/8/25 she worked for 3.25 hours from 11:53 AM to 3:12 PM. 4. Interview with the DON on 2/12/25 at 1:49 PM revealed the RN on duty had been on-call and only worked 3.5 hours on 2/8/25. She stated she understood the nurse needed to be on duty for 8 hours; however, she confirmed the RN did not work 8 hours.

Based on medical record review, and resident, and staff interview the facility failed to provide rehabilitative services for 1 of 8 sample residents(#150). The findings were: 1. Review of the initial care plan dated 1/24/25 showed resident #150 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, myocardial infarction, and weakness. Further review showed a physician's order dated 1/23/25 to evaluate and treat for physical and occupational therapy. The following concerns were identified: a. Interview with the resident on 2/11/25 at 8:40 AM revealed s/he had been in the facility for more than a week and had not received any therapy. b. Interview with the DON on 2/12/25 at 1:46 PM revealed she had been unaware that the resident had therapy orders and confirmed the resident had not received any therapy services. c. Interview with the DOR on 2/12/25 at 2:12 PM revealed she had been unaware the resident had therapy orders, and confirmed the resident had not received any therapy services.

Based on observation, medical record review, staff interview, and review of incident reports, facility documentation and manufacturer's instructions, the facility failed to provide adequate supervision to prevent an elopement for 1 of 2 sample residents (#1) reviewed for elopement. In addition, the facility failed to ensure the wander management system (wanderguard) was tested per manufacturer's instructions to ensure it was working. The facility had 11 residents with a wanderguard. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 7/5/24. 1. Review of the 6/24/24 admission Minimum Data Set (MDS) assessment showed resident #1 had a diagnosis of non-Alzheimer's dementia and wandered daily. Review of the 6/17/24 elopement/exit seeking evaluation showed the resident had a history of wandering and was at risk for elopement. Review of physician orders showed a 6/17/24 order for a wanderguard [bracelet that is worn and triggers an alarm when the resident is near an opened exit door]. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, staff interview, and review of facility policy and procedures, the facility failed to ensure appropriate disinfection of reusable equipment was performed before contact with 4 of 4 sample residents (#1, #3, #7, #11). In addition, the facility failed to implement appropriate hand hygiene practices during 1 of 4 meal observations. The census was 39. The findings were: 1. Review of the medical record for resident #11 showed s/he most recent admission was on 1/30/24 and had diagnoses which included pneumonia. The following concerns were identified: a. Observation on 2/20/24 at 3 PM showed resident #1 and resident #11 were in their room and resident #1 was coughing. CNA #16 entered the residents' room, with the vitals tower brought from the nurse's station, applied the blood pressure cuff to resident #11's left arm, applied the pulse oximeter to a finger on the right hand, removed the thermometer from the tower, and slid it across the resident's forehead. Without cleaning the vitals tower equipment, the CNA performed same procedures for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, facility incident and employee record review, and review of facility policies and procedures and facility monitoring documentation, the facility failed to protect the resident's right to be free from verbal abuse and physical abuse by staff for 1 of 3 sample residents (#10) reviewed for abuse allegations. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 10/29/23. The findings were: 1. Review of a quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 6 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia, malnutrition, anxiety disorder, gastrointestinal hemorrhage, and diverticulosis of the large intestine without perforation, abscess, or bleeding. Further review showed the resident required moderate assistance (helper does less than half the effort) with eating, had weight loss which was not physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and policy and procedure review the facility failed to develop comprehensive care plans for 1 of 12 sample residents (#39). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #39 had an admission date of 4/18/23, a BIMS score of 7 out of 15, which indicated severe cognitive deficits, and diagnoses which included non-Alzheimer dementia, anxiety, and depression. The following concerns were identified: a. Observation on 11/13/23 at 4:17 PM showed the resident was packing his/her bags. At that time, s/he stated s/he was getting discharged and was ready to go home. Observation on 11/15/23 at 9:53 AM showed the resident was located in the front hall by the main entrance and had just got his/her nails painted. At that time, the resident stated the bracelet on his/her left wrist was an alarm and would go off if s/he goes out the door. b. Review of the physician orders showed Device: Wander guard every shift…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure appropriate hand hygiene and glove use to prevent cross-contamination for 1 of 2 sample residents (#19) observed during perineal care. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #19 had a BIMS score of 12 out 15, which indicated the resident was cognitively intact, and diagnoses which included non-traumatic brain dysfunction, depression, Wernicke's encephalopathy, muscle weakness, and other symptoms and signs involving cognitive functions and awareness. Further review showed the resident was dependent on staff for toileting hygiene. The following concerns were identified: a. Observation on 11/15/23 at 4:16 PM showed CNA #4 removed the resident's brief and performed perineal care on the resident, who was incontinent of urine, by wiping front to back. The CNA assisted the resident to roll to his/her left side, placed a clean brief under the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of daily staffing records, and staff interview, the facility failed to accurately post daily nurse staffing data. The census was 40. The findings were: 1. Review of the Daily Staffing for Nursing sheets for 10/6/22 through 10/18/22 failed to show the actual hours worked by the registered nurses, licensed practical nurses, and the certified nurse aides responsible for resident care per shift. 2. Interview with the administrator on 10/19/22 at 12:05 PM confirmed the daily staff posting failed to include the actual hours worked by the resident care staff.

Based on observation, review of the menu, staff and resident interview, and medical record review, the facility failed to follow the controlled carbohydrate (CCHO) diet menu for 9 of 9 residents (#1, #4, #5, #6, #7, #10, #12, #13, #16) observed who required that diet. The findings were: 1. Review of medical records showed the following diet orders: a. Resident #1 had an order for a CCHO diet dated 9/15/22. b. Resident #4 had an order for a CCHO diet dated 10/16/19. c. Resident #5 had an order for a CCHO diet dated 7/26/22. d. Resident #6 had an order for CCHO diet dated 9/2/22. e. Resident #7 had an order for a CCHO diet dated 8/18/22. f. Resident #10 had an order for a CCHO diet dated 7/21/17. g. Resident #12 had an order for a CCHO diet dated 10/11/22. h. Resident #13 had an order for a CCHO diet dated 7/6/22. i. Resident #16 had an order for a CCHO diet dated 3/15/22. 2. During an interview on 10/18/22 at 9:15 AM resident #5 stated the facility did not always follow his/her diabetic diet during meals. 3. Review of the menu for the lunch meal on 10/19/22 (signed by the certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide a written notice of transfer to 1 of 4 sample residents (#17) reviewed for a facility-initiated transfer. The findings were: 1. Review of the medical record for resident #17 showed the resident was hospitalized on [DATE] for evaluation and treatment for Geripsych. There was no evidence a written transfer notice was provided to the resident or resident's representative. 2. Interview with the DON on 10/19/22 at 5:24 PM revealed the facility was unable to locate the form for the discharge/ transfer. Further, she stated the resident knew about the discharge/transfer and wanted to go.

Based on observation, staff interview, and review manufacturer's instructions, the facility failed to ensure medications available for use were not expired in 1 of 3 medication storage units (rehabilitation hall cart). The findings were: 1. Observation on 10/19/22 at 11:22 AM of the rehabilitation hall medication cart showed 2 humalog 100 units/milliliter (ml) kwikpens without a written open date. Interview with RN #1 at that time confirmed the medications were not dated and were for resident use. 2. Interview with the DON on 10/19/22 at 11:29 AM revealed it was the facility's expectation for the nurses to put an open date on insulin pens when they were removed from the refrigerator and then dispose of them when the medication expired. Further, she revealed the facility did not have a policy of medication expiration. She stated .the nurses are to follow what the pharmacy says. 3. Review of manufacturer's instructions for Humalog KwikPens found at http://www.humalog.com/taking-humalog/using-u100-u200-kwikpen#storage-and-disposal-kwikpens, retrieved 10/20/22, showed .Opened Humalog…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.