Inspection Reports for
Sage Mountain Senior Living

The complaint involved an allegation that a caregiver hit Resident 1 on 01/28/2026. The resident reported being hit with a voucher but could not specify details. A body assessment showed no marks or discoloration. The facility conducted an internal investigation and ensured proper reporting protocols were followed. The alleged staff denied the incident and is to receive any necessary training.

Interviews with the resident, staff, and other residents, as well as a file review, revealed no clear evidence or witnesses to the alleged incident. The resident with dementia was unable to provide clear information, and the alleged staff denied the accusation. No immediate health and safety concerns were observed during the visit.

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 visit was complaint-related, following up on a self-reported death incident. No substantiation status or findings were issued yet as further investigation is needed.

During the visit, the Licensing Program Analyst interviewed the Executive Director, attempted to interview two residents, reviewed files, and collected documents relevant to the investigation. It was determined that further investigation is required prior to issuing findings.

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.

A medication audit was conducted for two residents, revealing that some medications were not properly documented on the centrally stored medications and destruction record (CSMDR), including missing start dates and fill dates. However, all information was available on the facility's online system. No deficiencies were cited at this time.

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 visit was triggered by two self-reported Unusual Incident/Injury Reports: Resident #1 suffered a fractured pelvis after being found sitting on the floor with hip pain; Resident #2 was found lying on the ground with bleeding around the left ear and was admitted for two small subdermal brain bleeds.

The inspection found no immediate health and safety concerns during the visit. The Licensing Program Analyst conducted interviews and reviewed pertinent information related to the incidents. A follow-up visit may occur if warranted.

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 investigation was triggered by a self-reported incident on 2025-03-02 where Resident 1 took a bottle of pills and was transported to the hospital. The resident had left the community on 2025-02-18 and returned on 2025-02-27 without disclosing a prescription filled outside the facility on 2025-02-19. The complaint remains under further investigation.

The Licensing Program Analyst conducted interviews, a file review, and a medication audit related to the incident. No citations were issued during this visit, and further investigation is planned with a return visit scheduled.

The visit was complaint-related, following up on a self-reported death incident involving Resident #1. The incident was referred for further investigation by the Community Care Licensing Investigations Branch.

The Licensing Program Analyst conducted an interview with the Executive Director, toured the facility, and obtained pertinent documents despite a power outage. The incident was referred to the Community Care Licensing Investigations Branch for further review and possible investigation.

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 involved an alleged sexual assault of Resident #1 by Staff #1 on 07/06/2023. Resident #1 reported being kissed on the mouth by Staff #1 during assistance with moving in bed. Staff #1 and Resident #2 denied the allegation. The facility suspended Staff #1 pending investigation. The Department found the allegation unsubstantiated due to conflicting statements and lack of evidence.

The investigation included interviews with residents and staff, review of facility records, and coordination with law enforcement. Conflicting statements were found regarding the alleged sexual assault, and the Department determined there was insufficient evidence to substantiate the allegation. The allegation was deemed unsubstantiated.

The facility reported that Resident #1 and Resident #2 had their credit card information stolen, with investigations ongoing and police reports filed. The facility has a theft and loss program in place and is assisting the residents.

The visit was triggered by a complaint related to theft of credit cards involving Resident #1 and Resident #2. The complaint is under investigation with police reports filed; no substantiation status is provided.

The facility has a theft and loss program in place and is conducting an investigation to assist the residents. Police reports were made by the residents or their family members. The Executive Director reported that one resident's credit card information was stolen outside the facility.

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 investigation was triggered by allegations that staff did not respond timely to a pendent call for assistance during a choking incident involving Resident #1. The investigation found sufficient evidence that staff did not respond timely to a stat assistance call and that staff member S2's first aid certification was expired.

The investigation found insufficient evidence that staff failed to respond to a pendent call timely, but sufficient evidence that staff did not respond timely to a stat assistance call during a choking incident, taking approximately 7 to 8 minutes to respond and failing to perform life-saving procedures. Additionally, it was found that staff member S2's first aid certification had expired and was not current during the incident.

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 Licensing Program Analyst conducted interviews, document reviews, and a tour related to the resident's death. No deficiencies were observed during the visit.

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.

No deficiencies were cited at the time of the inspection. The cause of death was unknown, and the licensing analyst will return if further investigation is needed upon receipt of the death certificate.

The visit was triggered by a death report received on 2023-04-07 concerning Resident #1. The cause of death was unknown at the time of inspection. The death certificate was not yet available, and further investigation may occur after its receipt.

No deficiencies were cited at the time of the inspection. The Licensing Program Analyst reviewed records for Resident #1 and will return for further investigation if needed upon receipt of the death certificate.

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 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 alleged that Resident #1 was physically abused while in care. The investigation included interviews, record reviews, and facility tours. The allegation was deemed unsubstantiated due to lack of evidence.

The investigation found insufficient evidence to substantiate the allegation of physical abuse. Records showed discoloration on the resident but no evidence of injury was found during medical evaluation, and the resident denied pain or discomfort. No deficiencies were cited.

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 allegation was that facility staff were not allowing the LTCO to have confidential meetings with residents. The allegation was found to be unsubstantiated based on interviews and record reviews.

The investigation found that LTCO representatives were allowed to move freely within the facility and visit residents as they chose. One LTCO representative remained inside a resident room for the entire visit by choice and did not meet privately with any residents. Based on the information gathered, the complaint allegation was deemed unsubstantiated.

The complaint alleged that facility trash was not emptied regularly. After interviews with six residents and one staff member, and a physical plant tour, the allegation was found unsubstantiated.

The investigation found no issues or concerns regarding trash removal; the allegation was deemed unsubstantiated based on interviews with residents and staff and observations during the physical plant tour.

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.