Sage View Care Center

In the surveyor’s words

From the most serious findings on record at Sage View Care Center, in the surveyor’s own words.

• Actual harm, isolatedF805Jan 15, 2026

  Based on medical record review, staff interview, and facility incident review, the facility failed to ensure food was prepared in a form to meet resident needs for 1 of 9 sample residents (#1) reviewed. This failure resulted in actual harm to resident #1. Corrective measures were implemented prior to the survey and compliance was determined to be met on 1/9/26. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had no long-term or short-term memory impairment and diagnoses which included cerebral palsy and esophageal obstruction. Further review showed the resident required a mechanically altered and therapeutic diet. […]

• No harm, potential for more than minimal, widespreadF727Feb 13, 2025

  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.

• No harm, potential for more than minimal, patternF880Feb 21, 2024

  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. […]

• No harm, potential for more than minimal, patternF732Oct 20, 2022

  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.

• No harm, potential for more than minimal, patternF803Oct 20, 2022

  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. […]