Sage Post Acute

In the surveyor’s words

From the most serious findings on record at Sage Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 9, 2026

  Based 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). […]

• Actual harm, isolatedF689May 12, 2026

  Based 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). […]

• No harm, potential for more than minimal, widespreadF727Aug 14, 2025

  Based 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. Findings: During a concurrent interview and record review on 8/12/25 at 9:00 a.m., with the Accounts Payable/Payroll (APP),the facility's licensed staffing schedules for the month of January 2024 through March 2024 were reviewed, the staffing schedule indicated there were no RNs scheduled to work eight hours a day during the following dates: 1. For the month of January 2024: 1/1/24; 1/6/24; 1/7/24; 1/13/24; 1/14/24; 1/20/24; 1/21/24; 1/26/24; 1/27/24 and 1/28/24. 2. […]

• No harm, potential for more than minimal, widespreadF727Nov 1, 2022

  Based on interview and record review, the skilled nursing facility did not have a Director of Nursing working full-time for eight months. This failure resulted in the lack of nursing staff oversight and had the potential for substandard provisions of care and patient needs to go unmet. Findings: In concurrent interviews on 7/5/2022 at 9:45 a.m., with the Director of Nursing (DON 1) and the Social Services Director (SSD), DON 1 stated she had been back working at the facility for one week after being gone for eight months. On 7/5/22 at 11:10 a.m., SSD stated there was a Director of Nursing at the facility (DON 2) while DON 1 was gone and stated, If we needed a DON, DON 2 would come in for a couple of hours and then leave. […]

• No harm, potential for more than minimal, patternF578Aug 14, 2025

  Based 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. Findings: 1. […]