Sapphire Nursing And Rehab At Goshen

In the surveyor’s words

From the most serious findings on record at Sapphire Nursing And Rehab At Goshen, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF725Feb 7, 2023

  Based on interview, and review of facility records during the Recertification Survey beginning on 1/31/2023 and ending on 2/7/2023, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident population in accordance with resident needs. Specifically, three of three resident care units reviewed for sufficient staff did not consistently meet the facility staffing minimum. […]

• No harm, potential for more than minimal, isolatedF645Aug 19, 2026

  Based on record review and interviews conducted during an abbreviated survey, the facility did not ensure referrals to the New York State Office for People With Developmental Disabilities (OPWDD) for Preadmission Screening and Resident Review (PASRR) Level II evaluations were completed as required prior to admission for two (Residents #3 and #4) of three residents reviewed for Preadmission Screening and Resident Review requirements. Specifically, 1. Resident #3, who was admitted to the facility on [DATE], had a preadmission Level I SCREEN dated 01/12/2026 from the hospital identified an intellectual/developmental disability; however, a referral to the New York State Office for People With Developmental Disabilities for a Preadmission Screening and Resident Review Level II evaluation and… […]

• No harm, potential for more than minimal, isolatedF657Apr 16, 2025

  Based on record review and interviews conducted during the recertification survey from ,d+[DATE]-[DATE], the facility did not ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after a change in condition and conversion to comfort care for 1 of 1 residents investigated for death . Specifically, Resident #113 was admitted to the facility for short term rehabilitation, had a decline in condition during their stay, elected comfort care, and expired at the facility, and the Comprehensive Care Plan did not reflect these changes. Findings include: Resident #113 was admitted to the facility for short term rehabilitation with diagnoses that included fracture of pubis, bacteremia, and pain. […]

• No harm, potential for more than minimal, isolatedF812Apr 16, 2025

  Based on observation, interview, and record review, conducted during the recertification survey from 4/10/2025 to 4/16/2025, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1) the kitchen had damaged tile and linoleum flooring and 2) staff did not wear a hairnet in order to prevent hair from contacting food. The findings include: A facility policy dated 3/1/2022 and titled Preventive Maintenance and Inspections documented Preventive Maintenance is the care and servicing by personnel for the purpose of maintaining fixtures, equipment and facilities in a satisfactory operating condition by providing for systematic inspection, detection and correction of incipient failures… […]

• No harm, potential for more than minimal, isolatedF880Apr 16, 2025

  Based on record review, and interviews during a Recertification Survey (4/10/2025 - 4/16/2025), the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure an infection surveillance plan based on facility assessment was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks. The findings include: A facility policy titled Infection Prevention and Control Program dated 12/01/2017 and last reviewed on 3/21/24 documented the elements of the Infection Prevention and Control Program consists of coordination/oversight, surveillance, data analysis, outbreak management, enhanced barrier precautions,… […]