Sapphire Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 14, 2025

  Based on medical record review, staff interview, review of the police reports, review of the facility Self-Reported Incidents (SRI), review of the website www.accuweather.com, review of the incident/accident log, review of the hospital discharge record, review of the incident report, review of the staff witness statements, and policy review, the facility failed to provide adequate interventions and/or supervision to prevent a cognitively impaired resident (Resident #10), who was assessed at risk for elopement, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #10 eloped from the facility and the resident was found by the police 0.5 miles from the facility. […]

• Immediate jeopardy, isolatedF627Sep 22, 2025

  Based on closed medical record review, hospital record review, review of a facility investigation, review of the facility assessment, policy review, and interview, the facility failed to develop and implement an effective discharge planning process focusing on the safety and total care needs of Resident #23 to ensure the resident was discharged to a safe location with continuity of care post-discharge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death beginning on 08/12/25 when Resident #23, who had been admitted to the facility with a known diagnosis of alcohol abuse, was discharged from the facility without evidence the resident had a safe location in which to go. […]

• Immediate jeopardy, isolatedF684May 12, 2025

  Based on closed medical record review, staff interviews, Emergency Medical Technician (EMT) interview, review of Emergency Medical Services (EMS) run report, review of the tracheostomy handbook, and review of the facilities policies and procedures, the facility failed to ensure the proper respiratory support was provided to a resident who was experiencing respiratory distress. This resulted in Immediate Jeopardy and serious life-threatening harm and/or negative health outcomes when Resident #199, who had a tracheostomy (a small surgical opening through the skin and into the windpipe), was not administered respiratory support including suctioning the tracheostomy, administering an as needed breathing treatment which was ordered for shortness of breath, changing the inner cannula of the… […]

• Immediate jeopardy, isolatedF760Jun 27, 2023

  Based on medical record review, review of hospital discharge summaries, resident and staff interviews, and facility policy review, the facility failed to ensure Resident #58 was administered diabetic medication as ordered. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #58 was readmitted to the facility from the hospital with orders for Lantus (a long-acting insulin) and Humalog (a fast-acting insulin) and Resident #58 was not administered any diabetic medications or insulin on [DATE] or [DATE]. On [DATE] at approximately 11:30 A.M., Resident #58 was sent back to the hospital when Resident #58's blood sugar was checked and showed high. […]

• Immediate jeopardy, isolatedF791Jun 27, 2023

  Based on medical record review, review of hospital records, review of dental records, staff interview, and facility policy review, the facility failed to ensure one resident (Resident #72) was provided dental care in a timely manner. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or medical emergency on 03/30/23 when Resident #72 was readmitted to the facility from the hospital where Resident #72 had been treated with three antibiotics for sepsis (the body's extreme response to an infection) caused by several abscessed teeth. Resident #72 was discharged from the hospital with an order to follow-up with a dentist as soon as possible (ASAP) for tooth extractions. […]