Sapphire Nursing and Rehab at Goshen

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 4/10-[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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00362632) the facility did not ensure that a resident who entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for 2(Resident #1,#2) out of 3 residents reviewed for indwelling catheters. Specifically, (1) Resident #1 was admitted to the facility on [DATE] with a Foley catheter in place, and they were never assessed or trialed for the Foley catheter removal, as per the facility policy. (2) Resident #2 was admitted to the facility on [DATE] with a Foley catheter in place, and they were never assessed or trialed for the Foley catheter removal, as per the facility policy.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00362632) the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit and a decision about the continued appropriateness of the resident's current medical regimen for 1 out of 3 residents (Resident #1, #2) reviewed for Foley catheter use. Specifically, (1) Resident #1 was admitted to the facility with a Foley catheter on 10/18/2024. Attending Physician #1 did not address Resident #1's Foley catheter when they completed their history and physical. The history and physical documented Resident #1 had stress incontinence and the catheter section documented not applicable. Resident #1 was discharged back to the hospital on [DATE] with the foley catheter still in place. (2) Resident #2 was admitted to the facility with a Foley catheter on 11/16/2024. [...]

Inspectors wroteBased 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. In addition, during a Resident Council meeting, residents verbalized staffing was inadequate.

Inspectors wroteBased on observation, interview, and record review conducted during Recertification Survey between 1/31/2023 -2/7/2023, the facility did not ensure they provided a safe, clean, comfortable, and homelike environment. Specifically, on 3 of 3 units there were window curtains hanging off the tracks, peeling chipped wall paint, damaged sheet rock, and dirty/stained bed mattress were observed.

Inspectors wroteBased on observation, record review and interview conducted during 1/31/23-2/7/23 Recertification Survey the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and/or the comprehensive person centered care plan for 1 of 5 residents (#24) reviewed for pressure ulcers and 1 of 1 resident (Resident #65) reviewed for skin conditions. Specifically, 1) bilateral heel protectors were not applied for Resident #24 who was assessed as high risk for pressure ulcers and had bilateral heel pressure ulcers and 2) the facility did not provide routine wound assessments and or skin checks for Resident #65 assessed with right heel bogginess upon admission.

Inspectors wroteBased on observation, record review, and interview during the recertification survey from 1/31/23 through 02/7/23, the facility failed to ensure residents remained free of accident hazards, for 1 of 3 resident reviewed for accidents. Specifically, Resident #60 was not provided liquids in the prescribed consistency, and was not provided supervision during meals as planned.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that proper cooling procedures were implemented for food that was cooked and cooled to be used at a later date. Specifically, temperature logs used to document cooling temperatures to ensure that food is cooled according to acceptable timeframes were not being completed.

Inspectors wroteBased on observation, interview and record review during the recent recertification survey, it could not be ensured that the facility implemented care plan intervention for positioning devices. Specifically, Resident #75 required wheelchair positioning devices in order to sit upright in the chair. This was evident for one resident reviewed for positioning.

Inspectors wroteBased on record review and interview during the recent recertification survey, it could not be ensured that the facility reviewed, revised and updated a nutrition care plan to address the declining nutritional status for Resident #82. This was evident for 1 of 4 residents reviewed for nutrition.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey it cannot be ensured that the facility provided care and services to address the resident's skin and wound care needs in accordance with professional standards of practice 1 of 5 residents (Resident #55) reviewed for pressure ulcers. Specifically, physician's orders/treatments were not put in place for the care/treatment of left lower extremity deep tissue injuries.

Inspectors wroteBased on record review, observation and interview during the recent recertification survey, the facility did not ensure that acceptable parameters of nutritional status were maintained for Resident #82. This was evident for 1 of 4 residents reviewed for nutrition.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it could not be ensured that the facility reviewed each resident's drug regime to certify that they are free of unnecessary medications for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. Specifically, a lack of documentation to indicate the continued use of an antipsychotic medication.

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure that staff followed proper hand hygiene during wound care treatment for 1 of 5 residents (#55) reviewed for pressure ulcers.

Inspectors wroteBased on record review and interview during the most recent recertification survey, the facility did not ensure that written notification was sent to the families (or resident representative) and the ombudsman with information regarding transfers from the facility to the hospital. This was evident for 2 of 2 residents reviewed for hospitalization (Residents # 93, #9).