Ellen Sagar Nursing Center

In the surveyor’s words

From the most serious findings on record at Ellen Sagar Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 17, 2023

  Based on review of the facility policy, interviews, and observation, the facility failed to provide supervision to 1 of 5 residents (R)3 to prevent accidents and hazards. R3 eloped from the facility on 03/13/23 between approximately 7:20-7:30 PM. Because no staff were on the hallway to hear the door alarm sounding when the resident exited, it was not known she had eloped - placing her at risk of serious harm. No staff were searching for the resident when she was found by Dietary Assistant (DA)1, who was leaving at the end of the shift. […]

• Actual harm, isolatedF656Jun 4, 2021

  Based on observations, record review, and staff interviews, the facility failed to develop a comprehensive care plan addressing functional limitation in range of motion (ROM) for 1 of 5 sample residents (Resident (R) #6) reviewed for ROM. As a result, R6 sustained a decline in ROM in his/her left-hand/fingers. The Findings include: Review of the facility Face Sheet revealed R6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/05/2021, R6 had a Brief Interview for Mental Status score of 12 out of 15, which indicated R6 was moderately cognitively impaired. R6 required extensive assistance with two-person assist with activities of daily living (ADLs). […]

• Actual harm, isolatedF688Jun 4, 2021

  Based on observation, record review, and staff interviews, and record review, the facility failed to ensure 1 of 5 sample residents (Resident (R)#6) reviewed for functional mobility for limited range of motion received the care and services to assist the resident and maintain, improve, or prevent an avoidable decline in range of motion (ROM). As a result, R6 sustained a decline in the ROM in his/her left-hand/fingers. The Findings include: Review of the facility Face Sheet revealed R6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/05/2021, revealed R6 had a Brief Interview for Mental Status score of 12 out of 15, which indicated R6 was moderately cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF761May 19, 2026

  Based on observation, interview, and review of facility policy, the facility failed to ensure medications were properly stored and expired medications were removed from storage, for 4 of 4 medication carts.Findings include:Review of the facility policy titled Safe and Sanitary Handling, Storage, and Wastage and Controlled Substance Management with an effective date of 04/2026, revealed, Policy: To ensure medication are stored properly, handled, transported, and stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and safety, and shall only be accessible to authorized personnel.During an observation on 05/19/26 at 11:35 AM, of the Medication Cart/Back #1 with Licensed Practical Nurse (LPN)4, revealed the following: Acid Gone Antacid that… […]

• No harm, potential for more than minimal, patternF584Mar 7, 2025

  Based on observation and interview, the facility failed to ensure a clean, comfortable, and homelike environment by failing to maintain clean floors and walls in common areas. Findings included: On 03/04/25 at 10:50 AM, an initial tour of the facility was conducted. The walls and baseboards on both sides of the hallway leading to Unit Two were heavily scuffed and soiled. Additionally, there was both loose dirt and buildup observed in the corners. On 03/04/25 at 12:00 PM, an observation of the lunch meal was conducted in the facility's main dining area. The walls, baseboard, and floors near the kitchen entrance from the dining room were heavily soiled. On 03/07/25 at 10:09 AM, an interview was conducted with the Environmental Services (EVS) Supervisor. […]