Inspection Reports for
Sage Mountain Senior Living

The complaint was substantiated. The allegation was that facility staff did not notify authorized representatives of falls involving Resident 1. The investigation found that the facility did not notify Individual #1, who was listed as the responsible person in the electronic medical record system, and there was no valid Power of Attorney documentation on file. Individual #1 denied being notified and denied being the POA. Individual #2 was contacted after a fall but was four hours away and not the preferred contact. The facility was cited for this violation.

The investigation substantiated the allegation that the facility failed to notify the authorized representative of Resident 1 about three falls, posing a potential health, safety, and personal rights risk. The facility lacked proper documentation of the resident's Power of Attorney and did not comply with notification requirements.

The facility was generally found to be in compliance with health and safety standards, including operable kitchen appliances, clean common areas, and functioning fire safety equipment. However, five restrooms had hot water temperatures exceeding the regulatory maximum, posing an immediate health and safety risk.

The complaint investigation was substantiated, involving neglect and lack of care and supervision where Resident (R1) choked to death without medical intervention while under facility care.

The Department determined that a civil penalty is warranted due to the facility's failure to ensure sufficient competent personnel were present to meet the resident's needs, resulting in the resident choking to death. A civil penalty of $14,500 was issued in addition to a prior $500 penalty.

The complaint investigation was substantiated for the allegation that staff refused to assist Resident #1 to the bathroom on 06/18/24, resulting in paramedics being called. The allegations regarding improper assessment for level change and improper rate change were unsubstantiated.

The allegation that staff refused to assist a resident to the bathroom was substantiated, with evidence showing staff could not assist due to equipment issues and paramedics were called to assist. The allegations regarding improper assessment and rate changes were unsubstantiated based on file reviews and interviews.

The complaint was substantiated based on a self-reported Report of Suspected Elder Abuse SOC341 involving Resident 1 and Staff 1, where Staff 1 failed to report or advocate for timely medical care for the resident's infected wound.

The licensee failed to ensure timely medical care for a resident who had an infected wound for over 10 days before being seen by a medical provider, posing an immediate safety and personal rights risk. Staff failed to report or advocate for timely treatment, and the resident was hospitalized for cellulitis.

The visit was complaint-related due to a self-reported Unusual Incident/Injury Report about missed medications for Resident #1. The complaint was substantiated with a cited deficiency.

The inspection found that Resident #1 did not receive prescribed Synthroid medication on two separate days due to a staff error in updating medication orders. The resident showed no symptoms or reactions, and staff received medication training. A Type B deficiency was cited for failure to assist residents with self-administered medications as required.

The complaint investigation substantiated allegations that staff failed to report changes in condition, delayed medical attention, mismanaged medication, neglected resident needs, and allowed multiple falls. An immediate civil penalty of $500 was issued on October 26, 2022, and a further penalty of $9,500 was issued on 03/24/2025 for serious bodily injury.

The investigation found that the facility failed to seek guidance for a resident's significant changes in condition, including weight loss, hypoglycemic episodes, and falls, resulting in dehydration, acute kidney injury, and hospitalization. A civil penalty of $9,500 was issued for serious bodily injury.

The complaint investigation was substantiated for inadequate staffing to assist residents, with evidence including resident call pendant wait times averaging 38 minutes, staff interviews confirming understaffing in 2023, and reports of residents waiting up to two hours for assistance. The allegation regarding failure to assist with restroom needs leading to UTIs was unsubstantiated due to lack of medical evidence and unclear causation.

The allegation of inadequate staffing was substantiated based on interviews, file reviews, and resident call pendant data showing long wait times for assistance and staff shortages during 2023. The allegation regarding failure to assist a resident with restroom needs resulting in multiple UTIs was unsubstantiated due to insufficient evidence and lack of medical records confirming the UTIs or their source.

The complaint was substantiated. The allegation was that staff did not respond timely to resident call buttons, specifically citing Resident #1 who waited over 35 minutes for assistance on 09/11/2023. The investigation included file reviews, interviews with staff, residents, and technical support, confirming delays in response times.

The investigation substantiated the allegation that staff failed to respond promptly to resident call buttons, with documented delays of up to 35 minutes and 54 seconds to assist a resident. Multiple pendant calls showed wait times exceeding 15 minutes, posing a potential health and safety risk.

The facility was generally found to be in compliance with regulations, with clean and well-maintained common areas and kitchen. However, deficiencies were noted including unsafe storage of cleaning solutions and medications accessible to residents, unsanitary conditions in some resident rooms, and sticky floors in certain restrooms.

The visit was conducted in conjunction with an initial 10-day complaint visit (CC #29-AS-20241003142431). The deficiencies cited were not related to the complaint allegations.

During the facility tour, cleaning supplies were found left unattended in a hallway accessible to residents, posing an immediate health and safety risk. The Executive Director advised staff to lock away cleaning supplies to prevent resident access.

The complaint investigation was substantiated. Allegations included failure to meet resident toileting needs timely and billing for services not received. Investigations included interviews, record reviews, and observations confirming these issues.

The investigation substantiated that staff failed to respond timely to resident calls for toileting assistance, resulting in the resident being wet for extended periods, and that the facility billed the resident for personal care services during a period when the resident was absent from the community, without issuing the appropriate credit or refund.

The complaint alleged that staff did not respond timely to Resident #1’s call for assistance and did not seek medical assistance for the resident. The investigation found these allegations substantiated based on witness statements and medical records. Other allegations about pressure injuries and facility odor were unsubstantiated.

The investigation substantiated that staff failed to respond timely to Resident #1's call for assistance and did not seek medical assistance after a fall and subsequent emergency. Other allegations regarding pressure injuries due to neglect and facility odor were unsubstantiated. A $250 civil penalty was assessed due to repeat violations.

The report is an amended document with a citation removed following an appeal. No specific deficiencies are detailed in the provided pages, and the deficiency section is intentionally left blank.

The complaint was substantiated. Staff admitted to taking resident's incontinence supplies once, and the facility failed to provide complete requested records despite multiple requests and communications. The records were incomplete, notably missing documentation of a fall on 12/30/22.

The investigation substantiated that staff took resident's incontinence supplies without safeguarding them and that the facility failed to provide complete requested records to the resident or authorized person, including documentation of a fall. Both allegations were supported by interviews, record reviews, and evidence.

The complaint investigation was triggered by allegations received on 2023-07-21. The investigation found the allegations regarding food service, resident needs, and transportation unsubstantiated. The allegations that staff do not respond timely to call pendants and do not safeguard residents' belongings were substantiated. Citations were issued accordingly.

The allegations of inadequate food service, unmet resident needs, and inadequate transportation services were deemed unsubstantiated based on interviews and observations. However, the allegations that staff do not respond to call pendants in a timely manner and do not safeguard residents' personal belongings were substantiated, resulting in citations issued for deficiencies related to theft and loss, and insufficient care response.

The complaint alleged neglect and lack of supervision resulting in Resident #1 choking to death without medical intervention. The allegation was substantiated based on interviews, record reviews, and supporting documentation including EMS and Medical Examiner reports.

The investigation substantiated that Resident #1 choked to death due to neglect and lack of timely medical intervention by staff. It was found that staff did not perform life-saving procedures and delayed response to the emergency. Additionally, a citation was issued for staff not responding timely to a pendent call and for a staff member lacking a valid first aid certificate.

The facility was found to have several deficiencies including lack of emergency food and water supply, uncomfortable room temperature in bedroom #319, strong odor and drainage issues in bedroom #241, and maintenance issues such as a non-draining sink. Plans of correction were agreed upon with due dates.

The complaint was substantiated regarding incomplete initial and annual training of staff, including medication and first aid training. The allegation of unqualified staff cooking was unsubstantiated.

The investigation substantiated that facility staff did not complete required initial and annual training, including medication and first aid training, posing potential risks to residents. However, the allegation of unqualified staff cooking was unsubstantiated as only qualified staff were found to be cooking resident meals.

The visit was complaint-related under complaint control # 29-AS-20220322104533. The complaint was substantiated based on interviews and record review showing inadequate staff assistance during transfer leading to resident injury.

The investigation revealed that R1, a two-person assist resident, was transferred by only one staff member resulting in a skin tear injury. Interviews confirmed insufficient staff assistance during the transfer, posing a health and safety risk to the resident.

The visit was triggered by a deficiency observed during a complaint investigation. The deficiency was substantiated as the licensee failed to comply with the requirement for annual medical assessment for a resident with dementia.

During the complaint inspection, it was found that one resident with dementia had a medical assessment on file that was older than one year, which poses a potential health and safety risk to residents in care.

The complaint investigation was substantiated for allegations that medications were not given timely, staff mismanaged medications, and staff did not respond timely to pendent calls. The allegations that the administrator did not spend sufficient time in the facility and that staff falsified records were unsubstantiated.

The investigation substantiated allegations that medications were not given timely, staff mismanaged resident medications, and staff did not respond timely to pendent calls. Two allegations regarding the administrator's presence and staff falsifying records were unsubstantiated. Deficiencies related to medication administration and pendent call response times were cited.

The complaint investigation was substantiated regarding excessive wait times for resident assistance, with pendent call records from 06/14/2021 through 06/21/2021 showing multiple late response times and resident interviews confirming delays. Other complaints about facility disrepair, after-hours access, medication delivery delays, and staff assistance after hours were unsubstantiated.

The allegation that residents were made to wait an excessive amount of time for assistance was substantiated based on pendent call records and resident interviews showing multiple response times exceeding 20 minutes. Other allegations regarding facility disrepair, after-hours access, medication delivery delays, and staff assistance after hours were found to be unsubstantiated.

The complaint investigation was substantiated for the allegation that facility staff did not respond to resident's requests for assistance in a timely manner. Other allegations were unsubstantiated.

The allegation that staff did not respond timely to resident requests was substantiated with evidence of multiple pendent call response times exceeding 20 minutes. Other allegations regarding carpet stains, wheelchair maneuvering, food adequacy, and apartment cleaning were found unsubstantiated based on interviews and record reviews.

The complaint alleged staff drank alcohol while on duty. The allegation was substantiated based on social media evidence and staff interviews. A second complaint alleging staff left residents unattended was unsubstantiated due to insufficient evidence.

The investigation substantiated the allegation that staff drank alcohol while on duty, supported by social media photos and observations of an alcoholic beverage on facility grounds. Another allegation that staff left residents unattended during the potluck was unsubstantiated.

The visit was triggered by a deficiency observed during a complaint investigation. The deficiency was substantiated as Staff #1's criminal record clearance was not transferred to the facility, posing an immediate health and safety risk. Civil penalties of $100 per day for up to 30 days were assessed due to this repeat violation.

The facility failed to transfer and associate Staff #1's criminal record clearance to the facility despite the staff working there since August 2022. This deficiency poses an immediate health and safety risk and is a repeat violation from a prior citation within the last 12 months.

The complaint investigation was substantiated. Allegations included failure to report changes in condition to authorized representatives, failure to seek timely medical attention, medication mismanagement, failure to meet resident needs, and multiple falls. Resident #1 experienced significant weight loss, multiple falls, and medication errors. The facility failed to notify the physician and family timely and did not provide appropriate dietary accommodations.

The investigation substantiated all allegations, finding failures in reporting changes in condition, timely medical attention, medication administration, meeting resident dietary needs, and fall monitoring. The facility did not notify the resident's physician or family appropriately, failed to follow medication orders, and did not provide adequate vegan dietary options, resulting in significant weight loss and multiple falls for Resident #1.

The investigation was initiated due to a death report and multiple falls of Resident #1. Interviews and record reviews revealed no neglect or suspicious circumstances related to the death. The cause of death was listed as End Stage Ischemic Cerebrovascular Disease. The facility failed to report multiple falls to CCLD, which led to the cited deficiency.

No deficiencies were found related to R1's death, but a deficiency was cited for the facility's failure to report R1's multiple falls to the Community Care Licensing Division (CCLD).

The facility was generally found to be in compliance with health and safety regulations, including operational smoke and carbon monoxide detectors, appropriate hot water temperatures, and sufficient infection control measures. However, a deficiency was noted where the delayed egress auditory alarm in the memory care front desk/medication room was not operational, posing a potential health and safety risk.

The complaint was substantiated regarding food quality issues with spoiled and expired food items served to residents. The dishwasher-related allegations were unsubstantiated after inspection and interviews.

The allegation that food served was not of good quality was substantiated based on observation of expired and spoiled food items posing health risks. The allegation that the facility did not have an operating dishwasher and was unable to sanitize dishes was found unsubstantiated as the dishwasher was operational and maintained.

The visit was complaint-related following reports of a resident death and a memory care resident elopement. The elopement was substantiated as staff allowed the resident to leave the secured unit unassisted.

The investigation found that a new agency caregiver allowed a resident to leave a secured memory care unit unassisted, resulting in the resident eloping from the facility, posing an immediate health and safety risk. Additionally, the facility failed to post a phone number on the locked entry door for after-hours guests, creating a potential safety risk.

The complaint investigation was substantiated for the allegation that lack of care and supervision caused a resident to develop a pressure injury. The allegations regarding inadequate care causing a resident's death, retention of a resident with active tuberculosis, and a scabies outbreak were unsubstantiated.

The investigation substantiated the allegation that due to lack of care and supervision, Resident #1 developed a Stage IV pressure injury. The allegation that inadequate care resulted in Resident #2's death was unsubstantiated. The allegations that the facility was retaining a resident with active tuberculosis and had a scabies outbreak were also unsubstantiated based on medical record reviews and public health input. A $500 immediate civil penalty was assessed for the substantiated deficiency.

The visit was complaint-related under complaint control #29-AS-20220322104533. The deficiency was substantiated as a repeat violation from a previous citation issued on 11/22/2021.

Two staff members (S1 and S2) were found not to be associated with the facility, constituting a violation of criminal record clearance requirements. Civil penalties were assessed for this repeat violation.

The visit was triggered by a written report of an incident on 02/12/2022 involving Resident #1 and Staff #1. Further investigation was needed and planned. Additionally, a follow-up was conducted on a self-reported incident on 01/29/2022 where three memory care residents eloped through a delayed egress patio without injury.

The inspection found that the delayed egress alarm system in the memory care unit was not loud enough to be heard audibly in all areas, and staff were not carrying iPods that would alert them to the alarm, posing an immediate safety risk to residents. A deficiency was cited related to this issue.

The facility was generally compliant with health and safety regulations, including infection control, fire safety, and physical plant conditions. However, deficiencies were cited related to criminal record clearance for one staff member, unsecured cleaning supplies in the laundry room, and lack of emergency water supply for residents.

The complaint investigation was substantiated based on evidence that Resident 1's room was not cleaned and was in disrepair. The allegations included unclean resident rooms and room disrepair, both of which were confirmed during the investigation.

The investigation substantiated that Resident 1's room was not cleaned, with multiple stains from dog excrement on the carpet, and that the room was in disrepair, including an indentation in the kitchen wall and a missing toilet paper holder bracket. The facility corrected the deficiencies during the visit by replacing the carpet and repairing the wall and toilet paper holder.

The complaint was substantiated based on observations and evidence gathered during the investigation. The allegation of a malodorous room was confirmed.

The investigation substantiated the allegation that Resident 1's bedroom was malodorous due to a strong odor of pet urine. The facility failed to maintain the room in a clean, safe, and sanitary condition, posing a potential safety risk to residents.