Sagebrook Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sagebrook Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 12, 2022

  Based on observation, interview, and record review, the facility failed to adhere to food safety requirements for one of one kitchens reviewed for sanitation. The Dining Director failed to ensure the dish machine was washing and sanitizing dishes properly. This failure placed all residents at risk of foodborne illness. Findings included: During an observation and interview on [DATE] at 10:52 a.m., the Dining Director demonstrated the kitchen's process for washing dishes. The Dining Director stated the dish machine was a low temperature dish machine and the water needed to reach 110 degrees Fahrenheit. The Dining Director stated the water in the dish machine needed to run for a while first so it could heat up before starting ware washing. […]

• No harm, potential for more than minimal, widespreadF570Nov 3, 2021

  Based on record review and interview, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bond reviewed, in that: The facility's $40,000.00 surety bond was not enough to match the total residents' trust fund account balance for 08/01/2021 and 10/01/2021. This failure could place residents, at-risk of their personal funds not being assured. The findings were: Record review of the facility's surety bond dated 11/09/2020 revealed that it, was insured for $40,000.00 and was in effect from 11/09/2020 until 11/09/2021. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2021

  Based on observation, interview, and record review, the facility failed to label, date, and monitor refrigerated food, including, so it is used by its use-by-date, or discarded. The facility failed to label, date, and monitor refrigerated food and dispose of food stored in the walk-in-refrigerator after the use-by-date. This deficient practice could affect all residents by placing them at risk for foodborne illnesses. Findings include: An observation on 11-1-21, at 9:30 a.m. […]

• No harm, potential for more than minimal, patternF698Jul 16, 2026

  Based on interviews, and record review, the facility failed to ensure that residents who require dialysis receive such service, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 8 (Resident #2) residents reviewed for dialysis care. The facility failed to document Resident #2's post dialysis assessment in the medical record for 04/27/26, 06/23/26, 06/27/26, 07/02/26, 07/07/26, and 07/08/26. This failure could place residents at risk for untreated medical issues and diminished quality of care. […]

• No harm, potential for more than minimal, patternF759Jul 16, 2026

  Based on observations, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 25.93 % based on 7 errors out of 27 opportunities, which involved three residents (Resident #76, Resident#101 and Resident#39) of five reviewed for medication administration.The facility failed to ensure that the analgesic (Medications for relieving pain), anticonvulsant ( a drug primarily used to prevent or treat seizures and convulsions) and anti-parkinsonism medications of Resident #101, Resident #39 and Resident#76 were administered within the liberalized scheduled time (6:00am to 10:00am), before 8:00am for medications that were scheduled at 7:00am and before 9:00am that was scheduled at 8:00am,… […]