Sapphire Ridge Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF760Sep 20, 2021

  Based on record review, staff and physician interviews, the facility failed to prevent a significant medication error by not accurately transcribing and administering medication orders from the hospital discharge summary prescribed to treat a bacterial infection for 1 of 3 residents reviewed for medication errors (Resident #6). As a result, Resident #6 was not administered 24 doses of [MEDICATION(S)] (antibiotic) and 24 doses of [MEDICATION(S)] (antibiotic) and subsequently readmitted to the hospital for suspected severe [CONDITION(S)] (life-threatening complication of an infection) secondary to incompletely treated bacteremia (presence of bacteria in the bloodstream). […]

• Actual harm, isolatedF684Sep 20, 2021

  Based on record review and staff interviews, the facility failed to have a dependent resident assessed by a licensed medical professional when the resident complained of pain and swelling was noted to her leg that was subsequently determined to be a fracture which caused a delay of treatment for 1 of 3 residents reviewed for accidents (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's medical record revealed the following physician orders: · 11/19/20 read in part, Observation: pain - observe every shift. […]

• No harm, potential for more than minimal, patternF812May 7, 2026

  Based on record review, observations and staff interviews, the facility failed to date open containers of nutritional supplements and failed to remove nutritional supplements stored past the use by date in 2 of 3 nourishment room refrigerators (North and South Units). This practice had the potential to affect residents receiving nutritional supplements.Findings included:Observations of the nourishment room refrigerators on the North and South Units conducted on 05/06/26 at 10:29 AM through 10:41 AM with the Dietary Manager (DM) revealed:a. Stored in the North Unit nourishment room refrigerator was a one-quart sized nutritional shake with no date to indicate when it was opened. The manufacturer's label on the container read, use within 4 days after opening if refrigerated.b. […]

• No harm, potential for more than minimal, patternF803Mar 7, 2025

  Based on an observation of the lunch meal tray preparation, record review, and interviews with the Dietary Manager and staff, the facility failed to provide the correct portion size of beef hamburger steak for residents receiving a mechanically altered diet. This failure had the potential to affect 18 of 97 residents who received a lunch meal tray with a mechanically altered diet. Findings included: The facility's diet consistency census report dated 03/03/25 revealed 18 of 97 residents received a mechanically altered diet. The facility's planned menu for Wednesday (03/05/25) listed beef hamburger steak as the protein being served for lunch. The portion size listed on the menu indicated each plate received one beef hamburger steak. […]

• No harm, potential for more than minimal, patternF809Mar 7, 2025

  Based on observations, record review and resident, family and staff interviews, the facility failed to serve the lunch meal at the posted times on 03/05/25 and 03/06/25 in the main dining room during 2 of 3 meal observations. The findings included: Review of the facility's meal times schedule revealed lunch was to be served in the main dining room at 12:30 PM. a. Resident #54 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 had severe cognitive impairment, required partial/moderate assistance with eating and received a mechanically altered diet. Resident #101 was admitted to the facility on [DATE]. […]