Sapphire Care and Rehab Center

In the surveyor’s words

From the most serious findings on record at Sapphire Care and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 3, 2023

  Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of four residents sampled (Resident 2) resulting in serious injuries, a fractured arm and tooth. Findings include: The facility's policy titled Abuse Policy dated as reviewed by the facility on January 25, 2023, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. […]

• Actual harm, isolatedF600Nov 3, 2023

  Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of four residents sampled (Resident 2) resulting in serious injuries, a fractured arm and tooth. Findings include: The facility's policy titled Abuse Policy dated as reviewed by the facility on January 25, 2023, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. […]

• Actual harm, isolatedF600Jul 21, 2021

  Based on a review of clinical records, select facility investigative reports and abuse policy and staff interview it was revealed that the facility neglected to provide the care necessary to prevent physical harm, a serious injury, a diagnosed fractured elbow, sustained during an avoidable fall, by one of six residents reviewed (Resident 50). Findings include: Review of the facility's policy titled Abuse Protection with a policy review date of January 2021, indicated that each resident has the right to be free of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. […]

• No harm, potential for more than minimal, widespreadF880Oct 25, 2024

  Based on review of the facility's infection control tracking log, observations, and staff interview, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility, including protocols and provisions for Enhanced Barrier Precautions for 6 of six residents observed (Residents 70, 66, 52, 12, 83, and 33). Findings include: A review of a memo from The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, Ref: QSO-24-08-NH, CDC, Centers for disease control, dated March 20, 2024 regarding, Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of disease revealed, CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier… […]

• No harm, potential for more than minimal, widespreadF882Oct 25, 2024

  Based on staff interview, it was determined the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan. Findings included: The Centers for Medicare and Medicaid Services regulation S483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's Infection Prevention and Control Program. The IP must work at least part-time at the facility, physically work onsite in the facility, cannot be an off-site consultant, or perform the IP work at a separate location. […]