Sapphire Nursing at Wappingers

Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey the facility did not ensure necessary care and services were provided related to medication for one (Resident #3) of three (3) residents reviewed for quality of care. Specifically, medications were not available to be administered as ordered upon admission on [DATE]. Resident #3's medication list included Buprenorphine/Naloxone, a controlled substance used for opioid dependence treatment, anticonvulsant, neuropathic pain medication, anti-anxiety medication and antiviral medications. Pharmacy delivery records provided by the facility documented medications for Resident #3 were delivered to the facility between 11/03/2025 through 11/07/2025. There was no documented evidence that the pharmacy was contacted by facility staff when Resident #3 medications were not available. [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during an Abbreviated Survey, the facility did not ensure that a dietitian or other clinically qualified professional was sufficiently involved in carrying out the functions of the food and nutrition services. Specifically, the facility began a project to renovate the kitchen which temporarily prevents the facility from using the kitchen to cook resident meals. As an alternative, the facility is using an outside food vendor(a local restaurant) to provide resident meals, but the arrangement is without a system that provides dietitian oversight of meal preparation and consistently ensures that meals meet the daily nutritional, therapeutic, and other special dietary needs of the residents. Kitchen renovation project began in 2025. The use of the outside vendor began 02/02/2026. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey, the facility did not ensure food was procured, distributed, and served under sanitary conditions and at safe temperatures. Specifically, the surveyor observed the facility plating lunch meals on 03/30/2026. Hot foods were not maintained at safe temperatures during holding, as evidenced by temperatures declining below 135 F during continued plating. A test tray performed at the completion of meal service at 1:07pm on 03/30/2026 showed hot food items were not maintained at safe temperatures and were below acceptable ranges.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00373412, NY00374723), the facility did not ensure residents were free from abuse for 3 out of 3 residents (Resident #1, Resident # 2, Resident # 6) reviewed for abuse. Specifically, 1) On 2/26/2025 Resident #1 who had a known history of wandering, wandered into Resident # 2's room and Resident # 2 became agitated and put their hands on Resident # 1. Resident # 1 fell to the floor and kicked Resident # 2 in the leg. Resident #1 had no behavior care plan initiated before the incident. 2) On 3/11/2025 Resident # 1 was observed by staff in the doorway of their room holding their roommate(Resident # 6) by the collar. There was no documented behavior care plan was not initiated for Resident # 1 who had a known previous history of resident to resident altercation.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00360874), the facility did not ensure 1 out of 3 (Resident # 7) residents were free from significant medication errors. Specifically, Resident # 7 did not receive their physician ordered medication Enoxaparin Sodium (a medication to prevent blood clots) from 11/6/2024-11/12/2024. There were omissions on the Medication Administration Record with no documented nursing notes as to why the medications were not administered. 2) Resident #7 did not receive their medication Diazepam (a central nervous system depressant) from 11/6/2024-11/12/2024 as ordered by the physician. There was no documentation that the physician was notified or reasons why the medications were not administered. Resident #7 was transferred to the hospital on [DATE] for change in mental status.

Inspectors wroteBased on record review and staff interview during the abbreviated survey, (NY00340966), the facility did not ensure all allegations were thoroughly investigated for 1 of 4 residents. Specifically, Resident # 3 complained of pain in the shoulder and had x ray done on 4/26/2024 that showed a displaced right scapular fracture and osteopenia and was transferred to the hospital on 4/26/2024. The hospital history and physical report documented the resident reported that while in the facility when they were being repositioned, they heard a pop in their right shoulder. The facility did not provide any incident and accident report of the incident when requested by surveyors.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00342534) the facility did not ensure residents right to be free from abuse for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, on 8/5/2024 Resident #2 who was known to be physically/verbally abusive wandered into Resident #1's room, threw their items on the floor, tried to take away their walker and punched them with a closed fist on their arm. Resident #1 reported they were punched on the right arm by Resident #2. Resident #1 was assessed with no injuries and Resident #2 was discharged to the hospital for further evaluation.

Inspectors wroteBased on observations, record review and interviews during a recertification survey 4/8/24-4/17/24, the facility did not ensure residents received treatment and care in accordance with professional standards of quality for 4 of 6 residents (Residents #14, #27, #54 and #56) reviewed for quality of care. Specifically, 1) Resident #14 vascular wound dressing was not changed daily as ordered and was observed on 4/12/24 with a date of 4/9/24 on the dressing. 2) Resident #54 did not have post hospitalization appointments scheduled for follow up care. 3) Resident #56's order for compression stockings was not carried out and a follow up urology appointment was not scheduled. 4) Resident #27 did not receive daily wound care as ordered on 8 of 19 days from 3/29/24 to 4/16/24.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated surveys (NY0322448, NY00308142 and NY00320376) from 4/08/24 to 4/17/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule for multiple days and on all three shifts of staffing for each unit, the facility did not provide adequate staffing to meet the needs of the residents.

Inspectors wroteBased on record review and interview conducted during the recertification survey conducted from 4/08/24 to 4/17/24, the facility did not ensure certified nurse aide performance reviews were completed at least once every 12 months for 5 of 5 (Staff #'s 8, 9, 16, 17, and 18) certified nurse aides reviewed.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 4/8/2024-4/17/2024, the facility did not ensure that sanitary conditions were being maintained in the main kitchen area. Specifically, 1) undated and unlabeled food were in the freezer; 2) the dishwasher was not reaching the appropriate temperature; 3) staff were storing personal food in the refrigerator used for the residents' meals; 4) the exhaust wall fan was covered with dust and grease debris; 5) staff were not wearing beard cover while serving the residents their meals; and 6) tuna fish in a stainless steel container and lettuce were on the same shelf in the refrigerator.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey from 4/8/24-4/17/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (#22, #8, #14, #56, and #18) reviewed for infection control. Specifically, 1) staff did not change gloves after touching a resident and/or assistive device and before handing out Resident #8's food tray and staff were observed using the same hand while feeding Resident #22 and Resident #8; 2) staff did not wear a gown during a dressing change for Resident #14 on Enhanced Barrier Precautions; 3) staff did not wear a gown during a treatment for Resident #56 on Enhanced Barrier Precautions and 4) there was no documentation that oxygen tubing was changed weekly and as needed for Resident #18.

Inspectors wroteBased on observation, record review and interview during a recertification survey 4/8/24-4/17/24, the facility did not ensure residents had the right to a dignified existence for 8 of 8 residents reviewed for dining (Residents #54, #40, #39, #19, #25, #49, #56 and #28). Specifically, 1)clothing protectors were applied to Resident # 54, #40, #39, #19, #25, and #49 without first obtaining the residents permission; and 2) staff were observed standing over Resident #56 and #28 while feeding the residents their lunch.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 4/08/24 to 4/17/24, it was determined for 1 of 1 resident (Resident # 11) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation that a thorough investigation was completed or that there was timely resolution after Resident #11's report of missing clothing.

Inspectors wroteBased on staff interviews and record review during the recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that required documentation was sent to the receiving provider at the time of a hospital transfer for 1 of 2 residents (Resident #54) reviewed for hospitalization. Specifically, there was no documented evidence that a transfer summary was completed/sent when Resident #54 was transferred to the hospital.

Inspectors wroteBased on record review and interview during a recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that they provided written notice of the facility's Bed Hold policy upon transfer to all residents or residents' representative(s) for 1 of 2 residents (Resident #54) reviewed for hospitalization. Specifically, Resident #54 and/or their representatives were not provided written notice of the bed hold upon discharge to the hospital.

Inspectors wroteBased on observation, record review and interview conducted during a recertification 4/8/24-4/17/24, the facility did not ensure that necessary assistance and care were provided to carry out activities of daily living for 1 of 3 residents reviewed for activities of daily living (Resident #52). Specifically, Resident #52 was not toileted timely after calling for assistance.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 4/8/2024-4/17/2024, the facility did not ensure all residents were provided an ongoing program to support residents in their choice of activities and designed to meet their individual needs based on the comprehensive assessment and care plan and the preferences of each resident for 1 of 1 resident (Resident #50) reviewed for activities. Specifically, Resident #50 did not have an admission activity assessment completed to assess for and provide meaningful activities.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 4/8/24-4/17/24, the facility did not ensure that pain management was consistently provided for 2 of 2 residents reviewed for pain (Resident #56 and #43). Specifically, 1) Resident #56 did not receive Lidocaine patches as ordered and was not provided monitoring of their pain level to determine the need for an alternate treatment; and 2) Resident #43's pain level was not monitored.

Inspectors wroteBased on record review and interviews conducted during the recertification survey conducted from 4/08/24 to 4/17/24, the facility did not ensure that they consistently posted the daily nurse staffing information (daily resident census, total number/ actual hours worked by licensed nurses and certified nurse aides, and specific units) to be readily accessible to residents and visitors. Specifically, the daily nursing staff information was posted in the lobby area of the building on the other side of a coded door that the residents were unable to unlock unless accompanied by staff. Furthermore, the daily nursing staff information was not updated to reflect any staffing changes throughout the day and the specific units were not reflected on the posting.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 4/08/24 to 4/17/24, the facility did not ensure that the Facility Assessment was reviewed, accurate and updated as necessary. Specifically, the education, training, and competencies required for the certified nurse aides on the Facility Assessment were out of their scope of practice.

Inspectors wroteBased on record review, and interview conducted during a recertification survey from 4/8/2024-4/17/2024, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility was unable to provide a February or March 2024 infection/antibiotic tracking report.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 4/8/24-4/17/24, the facility did not ensure that residents were provided a safe, sanitary, and comfortable home-like environment. Specifically, 1. there was a strong urine odor in Resident #33 and 36's shared room and 2. the window curtain in Resident #25's room was hanging off the rod. The findings including: The facility policy entitled: Cleaning and Disinfecting Rooms Revised 11/12/2019. The facility policy stated environment surfaces will be disinfected on a regular basis, three times per week and when surfaces are visibly soiled. Clean curtains, window blinds, and walls when they are visibly soiled or dusty. Conduct monthly spot checks to ensure that all curtains and window treatments are cleaned and orderly. [...]

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated survey (NY00315011) conducted from 4/08/24 to 4/17/24, the facility did not ensure that the written description of the facility policy to implement advance directives was followed for one of one residents (Resident #0) of reviewed for Advance Directives. Specifically, cardiopulmonary resuscitation was administered and the resident was not sent to the hospital as per request for Resident #0 with orders for Do Not Resuscitate and orders to send to the hospital if necessary.

Inspectors wroteBased on record reviews and interviews conducted during an abbreviated survey (NY00306613, NY00323689), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source are reported immediately but no later than 2 hours, and the submission of the investigative report to the New York State Department of Health (NYSDOH) within 5 working days. This was evident in 2 of 4 residents (Residents #1 & #2) reviewed for Abuse. Specifically, (1) the facility reported a staff to Resident #1 abuse to the NYSDOH on 12/08/2022. The facility did not submit the required 5-day investigative report until 12/23/2022; (2) Resident #2 was observed with a bump on the left side of forehead measuring 8 cm x 6 cm (3.15 inches x 2.4 inches) and bruising to the left upper extremity measuring 18 cm x 10 cm (7 inches x 3.9 inches) on 09/11/2023 at 12 PM. [...]

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (NY00313016), the facility did not to ensure that the Family Representative (RR) of 1 of 4 residents (Resident #3) reviewed for notification was promptly informed of a change in the resident's physical status. Specifically, (1) Resident #3 had a room change for Covid isolation on 12/23/2022 and the family became aware when they visited the resident two days later; (2) Resident #'s RR was not notified when their right heel scab opened on 03/09/2023 new treatments were initiated.

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (NY00313016), the facility did not ensure prompt efforts were made to resolve a resident's grievance. This was evident for 1 of 3 residents (Resident #3) reviewed for Grievance. Specifically, (1) Resident #3's Family Representative (FR) complained to the facility on [DATE] that they were not notified about the presence of a right heel wound and that the scheduled wound dressing changes were not rendered but there was no documented evidence that the complaint was addressed; (2) there was also no evidence that a grievance form was initiated and completed for the residents' concerns in accordance with the facility policy.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00306613), the facility did not ensure that 1 out of 4 sampled residents (Resident #1) was free from physical, verbal, and emotional abuse. Specifically review of facility surveillance camera with no audio dated 12/06/2022 at 12AM revealed Resident #1 striking Certified Nursing Assistant (CNA #1) on the right shoulder as they sat in the day room. CNA #1 quickly stood up and with an intimidating stance, spoke and gestured for Resident #1 to return to their room. Resident #1 was observed cowering but did not leave. CNA #1 then physically turned and pushed Resident #1's upper back for the resident to return to their room. CNA #1 was observed grabbing Resident #1's right arm, but the resident was able to move their arm away. This incident was also witnessed by CNA #2 on the video footage. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recent recertification survey, the facility did not ensure that the interdisciplinary team (IDT) determine if a significant change assessment was warranted in the required 14-day period after a decline was identified for a resident who decline in functional status. Specifically, 1 of 1 resident (Resident # 9) reviewed for Activities of Daily Living (ADLs) had a functional decline in 2 or more areas based on 2 comparative Minimum Data Set (MDS, an assessment instrument); 2 a significant change MDS was not done within the required 14-day period after the decline was identified in order to determine appropriate plan of care and treatment.

Inspectors wroteBased on observation, interview and record review conducted during the recent recertification survey, the facility did not ensure that care plans with measurable goals, time frames and interventions were developed to address each resident's medical care needs. Specifically, care plans had not been developed to address issues related to: (1) multiple medical diagnoses with prescribed medications (Resident #53), (2) pain management for a resident with a spinal fracture (Resident #46), and ( 3) medical diagnoses of cirrhosis of the liver and hypothyroidism (Resident #37).

Inspectors wroteBased on record review and interview conducted during the recent recertification survey, the facility did not ensure care plans were reviewed and revised to address issues related to smoking and anxiety. Specifically, no interventions were initiated to address non-compliance with the facility's no smoking policy (Resident #2). and the plan of care addressing anxiety was not evaluated to address the continued use of 3 psychoactive medications (Resident #23).

Inspectors wroteBased on observation, interview and record review conducted during a recent recertification survey, the facility did not provide the necessary care and devices needed maintain or prevent further contracture for 1 resident (Resident # 41) reviewed for limited range of motion.

Inspectors wroteBased on observation, interview and record review conducted during the most recent re-certification survey, the facility did not ensure that 1 of 1 resident reviewed for respiratory care was provided appropriate care consistent with standards of practice and in accordance with a written plan of care. Specifically, the resident was being administered 3 liters of oxygen not in accordance with the physician's orders or written plan of care.

Inspectors wroteBased on record review and interview conducted during the most recent recertification survey, the facility did not ensure that each resident's drug regimen was free of unnecessary medications used for pain management and the treatment of hypertension. This was evident for 2 of 5 resident's reviewed for unnecessary medications (Residents #37 and #23) and 1 of 2 resident's reviewed for pain management (Resident #49). Specifically, there was inadequate pain monitoring for the use of opioids for Residents #37 and #49) and inadequate monitoring of vital signs for the use of an antihypertensive medication (Resident #23).

Inspectors wroteBased on observation, interview, and record review conducted during the recent recertification survey, the facility did not ensure that facility staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 1 of 3 residents (Resident #59) reviewed for pressure ulcer.