Sapphire Nursing At Meadow Hill

In the surveyor’s words

From the most serious findings on record at Sapphire Nursing At Meadow Hill, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 7, 2022

  Based on observation, interview and record review completed during the Recertification Survey conducted 11/28/2022-12/7/2022 the facility did not ensure that a resident assessed as high risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and to promote healing of a facility acquired stage 3 pressure ulcer for one of four residents (Resident #135) reviewed for pressure ulcers. Specifically, interventions and treatment measures were not implemented timely for Resident #135 who developed a facility acquired new and worsening stage 3 pressure ulcer. This resulted in actual harm that is not immediate jeopardy for Resident #135. […]

• No harm, potential for more than minimal, patternF584Dec 7, 2022

  Based on observation, interview, and record review conducted during the Recertification survey and Abbreviate Survey (NY304719) conducted from 11/28/22 to 12/7/22, it was determined the facility did not ensure that a safe, clean, comfortable, and homelike environment was maintained on 3 of 4 units (units 1 West, 1 East, and 2 West). Specifically, peeling wall paper, chipped paint, cracked broken plaster were observed in multiple resident rooms and dining room. The findings are: The facility Environmental Services Manager Job Description documented the primary purpose of the job position is to assure facility is maintained in an efficient, clean, safe, and comfortable manner. […]

• No harm, potential for more than minimal, isolatedF550Apr 1, 2025

  Based on observation, interview, and record review during the Recertification survey from 3/26/2025 through 4/1/2025, the facility did not ensure residents had the right to a dignified dining experience for 2 of 35 residents (Residents #2 and #113) reviewed for dignity while dining. Specifically, Certified Nurse Aides were observed standing over Resident #2 and Resident #113 while assisting with their meals. The findings include: The facility policy titled Quality of Life-Dignity dated 9/1/17 documented: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Resident #2 was admitted to the facility with diagnoses including malnutrition, non-Alzheimer dementia and cerebrovascular accident (stroke). […]

• No harm, potential for more than minimal, isolatedF584Apr 1, 2025

  Based on observation, interview, and record review conducted during the Recertification survey from 3/26/25 to 4/1/25, the facility did not ensure the Residents right to a safe, clean, comfortable, and homelike environment. This was evident for 1 of 35 resident rooms (Resident #10) and the hallways of 2 [NAME] Unit during observation of the environment. Specifically, Resident #10's room was observed with a strong odor of urine on multiple occasions and there was a strong odor of urine in hallways of 2 [NAME] unit. The findings included: The facility policy titled Homelike Environment reviewed 10/18/24 documented: It is the policy of facility to ensure that all Residents live in an environment that is clean and neat, with appropriate furnishings in a state of good repair. […]

• No harm, potential for more than minimal, isolatedF677Apr 1, 2025

  Based on observation, record review, and interview conducted during the recertification survey from 3/26/2025-4/1/2025, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 1 (Residents #90) of 5 residents reviewed for Activities of a Daily Living. Specifically, Resident #90, who required supervision with Activities of Daily Living, was observed during multiple observations with long, greasy hair, an unshaven face, and long, ungroomed fingernails. The findings include: The Policy and Procedure titled Activities of Daily Living was last reviewed on 10/1/2024 and documented. […]