The Sapphire at Maple Crest

In the surveyor’s words

From the most serious findings on record at The Sapphire at Maple Crest, in the surveyor’s own words.

• Immediate jeopardy, patternF600May 26, 2026

  Based on interview and record review the facility failed to ensure residents were protected from potential abuse when a non-staff individual, who was not screened, trained or authorized by the facility, was permitted to provide resident care including incontinence care, transfers and assisting residents to change clothes for 4 of 4 residents (R4, R5, R6, and R7) reviewed for abuse in the sample of 8.The Immediate Jeopardy began on 5/10/2026 when V5 (Non-Staff Individual) entered the building and began providing resident care.V1 (Administrator) was notified of Immediate Jeopardy on 5/26/2026 at 8:23 AM. […]

• Immediate jeopardy, patternF689Oct 2, 2024

  Based on observation, interview, and record review the facility failed to monitor temperatures of hot beverages prior to serving to residents, resulting in R1 sustaining full thickness (third degree) and partial thickness (second degree) burns to her thighs. This failure had the potential to affect 50 out of 75 residents residing in the facility that drink hot beverages and resulted in Immediate Jeopardy to their health and safety. The Immediate Jeopardy began on 9/15/24 when R1 sustained burns to her inner thighs from hot coffee. V1 Administrator was informed of the Immediate Jeopardy on 10/1/24 at 3:29 PM. […]

• Immediate jeopardy, isolatedF689Aug 31, 2023

  Based on observation, interview and record review the facility failed to ensure that a resident with a history of wandering and elopement attempts and a diagnosis of Frontotemporal Neurocognitive Disorder did not leave the facility unsupervised. The facility failed to have a policy and procedure in place to account for all residents after the emergency exit door alarm sounded and no residents could be observed outside. This failure resulted in R1 eloping from the facility at 7:15 PM on [DATE] and was found at approximately 8:55 PM on [DATE] by V13 (CNA) in the rear parking lot of a local business over 800 feet from the facility. On [DATE], R1 was last seen by facility staff between 6:00 PM-6:30 PM. The door alarm sounded at approximately 7:15 PM. […]

• Actual harm, isolatedF677Sep 25, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident was transferred out of bed in a timely manner and failed to provide incontinence care for a resident in a timely manner for 2 of 2 residents (R23, R57) reviewed for activities of daily living in the sample of 35.This failure resulted in R23 crying and voicing feelings of depression.The findings include:1. R23's admission Record, printed on 9/24/20245, showed she had diagnoses including, but not limited to major depressive disorder, mild cognitive impairment, dysphagia, and congestive heart failure. R23's recreational support care plan showed she is at the facility for long-term care and will attend meaningful activities that she chooses. […]

• Actual harm, isolatedF686Sep 16, 2025

  Based on interview and record review the facility failed to identify two areas of pressure until becoming unstageable. This failure resulted in one of the wounds requiring debridement and becoming a stage 4 pressure ulcer. This applies to one of three residents (R1) reviewed for pressure in the sample of three.The findings include:The facility face sheet shows R1 to have diagnoses to include Type 2 Diabetes Mellitus, peripheral vascular disease, stage three pressure ulcer of left buttock and stage four pressure ulcer of the right buttock. The facility assessment dated [DATE] shows R1 to be cognitively intact and requires moderate assistance with his personal hygiene. […]