Health inspection·September 7, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of five sampled (Residents 2). Residents Affected - Few Findings include: According to the RAI User's Manual, Section J1700, Fall history on admission/entry/reentry Assessment (OBRA or Scheduled PPS), the facility is to record a fall in the past month prior to admission /entry or reentry. A review of Resident 2's significant change MDS assessment dated [DATE], indicated that the resident did not have have a fall in the last month prior to admission/entry or reentry. However, a review of the resident's clinical record documentation indicated that the resident had a fall on March 27, 2023. According to the RAI User's Manual, Section J1700 , Fall history on admission/entry/reentry Assessment (OBRA or Scheduled PPS) This assessment also noted that the resident did not have a fall anytime in the past 2 to 6 months prior to admission/entry or reentry. The resident's clinical record revealed that the resident incurred falls on March 19, 2023, March 27, 2023, December 6, 2022, December 3, 2022, November 20, 2022, November 13, 2022 and November 12, 2022. Interview with the Employee 1, (LPN) on September 7, 2023, at approximately 1 PM confirmed that the resident's Significant Change Scheduled MDS Assessment Section J1700, parts A and B, was inaccurate. Page 1 of 8 395288 395288 09/07/2023 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide individualized care instructions for the resident's plans for care after discharge for one of two discharged residents reviewed (Resident 1) Findings include: A review of the closed clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses including colon cancer, sacral ulcer and muscle weakness. Resident 1 was discharged home on August 22, 2023. A review of Resident 1's clinical record, conducted during the survey ending September 7, 2023, revealed a Discharge Record form dated August 18, 2023, which included the resident's admitting diagnosis as pressure ulcer, sacral region, stage 4. A Discharge Summary form dated August 18, 2023, noted the reason for the resident's discharge as completed therapy and skilled care. In the section Social Services, question 8. indicated to List any follow up appointments scheduled, include name and speciality. The resident's attending physician and telephone number were noted and that the resident's son will schedule appointment upon discharge (from the facility). However, the resident's clinical record revealed a physician notation dated August 15, 2023, noting an appointment scheduled on August 23, 2023 at 2:30 PM with the outside wound care center for two-week follow up appointment. At the time of the survey ending September 7, 2023, there was no documented evidence that the discharge summary and instructions provided to the resident and/or the resident representative included the resident's scheduled appointment with the wound care center for a two-week follow-up. The documented discharge summary failed to include accurate and sufficiently detailed, individualized care instructions to ensure that the resident transitions safely from the facility to home. During an interview conducted on September 7, 2023, at approximately 2:00 PM, the Nursing Home Administrator was not able to provide evidence of sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another, including other practitioners, and caregivers involved with the resident's care. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 395288 Page 2 of 8 395288 09/07/2023 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently provide necessary supervision and effective safety measures to prevent repeated falls for a resident identified at high risk for falls and known unsafe behaviors, for one resident out of five sampled (Resident 2). Findings include: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses of diabetes, anxiety, nontraumatic chronic subdural hemorrhage and history of falling. A review of a significant change Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated April 28, 2023, revealed that the resident was moderately cognitively impaired with a BIMS score of 10 (BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) required assistance of staff for activities of daily living including transfers, ambulation and toileting. The resident's care plan, initially dated October 23, 2022, noted the resident's problem of being at risk for falls related to osteoarthritis. The resident's goal was to be free of falls as well as free of injury from falls. Interventions to include, anticipate and meet the residents needs, call bell within reach and proper footwear, bed and chair alarms and bilateral floor mats. A review of nursing documentation and fall reports revealed Resident 2's fall history as follows: - October 29, 2022, at 2:20 AM fall from bed, attempting to go to the bathroom, intervention, staff reminded resident to use call bell for assistance; -November 12, 2023, at 10:30 AM fall from bed, intervention every 15 minute checks for 72 hours; -November 13, 2022, at 4:50 PM fall from bed, interventions to continue every 15 minute watches and change bed to a low bed with perimeters; -November 19, 2022, at 11:15 PM fall from bed, interventions, encourage to call for assistance; -December 3, 2022, at 7:11 PM fall from bed, found with gash to the left side of his forehead, assessed by nursing, Physician and RP called. Sent to the hospital due to history of subdural hematomas. Testing completed at the hospital with no issues identified. The laceration was closed with adhesive and the resident returned to the facility; -December 6, 2022 10:06 AM fall from bed, attempting to go to the bathroom. Alarm sounding, Reeducated to wait for assistance. Nursing documentation dated December 13, 2022 at 2:02 PM revealed that the resident had a change in mental status, was seen by the physician and sent to the hospital for evaluation. Hospital documentation revealed a marginal increase in an intercranial bleed. The resident was admitted to the 395288 Page 3 of 8 395288 09/07/2023 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0689 hospital and readmitted to the facility on [DATE] at 6:07 PM and placed on every 15 minute checks. Level of Harm - Minimal harm or potential for actual harm Nursing documentation dated December 17, 2022 qt 7:18 Residents Affected - Some PM revealed Resident 2 continues to try to get out of bed. A nurse aide got the resident up in recliner and put him in the dining room. Nursing noted that every 15 minute checks continued. A nursing note dated December 18, 2022 at 6:17 AM revealed Resident 2 made several attempts to get out of bed unassisted and every 15 minute checks monitoring for safety were noted to continue. The resident was out of bed to the recliner chair at times. The resident continued to experience falls, during the time staff planned monitoring every 15 minutes for safety checks. According to the clinical record and fall reports the resident incurred the following falls: -January 3, 2023, at 1:52 PM - resident had a fall from wheelchair in the hallway while leaning foreward in the chair. Interventions to include, every 15 minute checks and resident encouraged not to lean foreward in the chair; -March 18, 2023, at 11 PM, fall from bed, interventions neuro checks per facility policy and every 15 minute monitoring; -March 27, 2023, at 10:19 PM fall from bed. Staff Called to Resident's room by his roommate. Resident was found sitting on the floor mat. He stated he was trying to get in his wheelchair. The wheelchair was in the hallway at the time. Documentation noted to continue current interventions. A physician order and care plan, noted that Resident 2 was placed on hospice services on April 28, 2023, for kidney failure. The resident experienced additional falls according to the clinical record and fall reports: -May 8, 2023 at 2:28 AM - the resident had a fall from bed attempting to get up and rolled out of bed. Documentation indicated for staff to continue current interventions; June 24, 2023 at 10:30 AM - the resident fell out of bed hitting his head on the bedside night stand. Nursing documentation dated June 24, 2023, at 10:30 AM revealed that nursing staff were called to resident's room by a nurse aide. The resident had a fall out of bed. The nurse aide stated that she was providing AM care, when she reached for resident's clothing, the resident rolled out of bed, hitting his head on the bedside nightstand. There was no loss of consciousness. The resident sustained a 3 inch laceration to the top of the head. Bleeding was stopped, area cleansed and covered with 4 steri-strips. Ice applied, and Tylenol given for complaints of headache. Neurochecks implemented and within normal limits at resident's baseline. The physician and responsible party notified. A review of the resident's plan of care at the time of the care revealed that he required the assistance of one staff for bed mobility and care at the time of the fall. On June 28, 2023 at 5:25 PM Resident 2 was seated in his hogback wheelchair in the lobby and suddenly fell forward from the wheelchair to his right side of body. The fall was witnessed by a nurse and 395288 Page 4 of 8 395288 09/07/2023 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0689 Level of Harm - Minimal harm or potential for actual harm nurse aide. Nursing assessed the resident and resident was placed back into the Highback wheel chair. When asked what happened, the resident stated that it happened before. Every 15 mins checks initiated (which were previously in effect and failed to prevent repeated falls). Physician contacted and gave order to monitor. Therapy to evaluate Highback wheelchair. The facility noted that the resident is impulsive and will not ask for assistance. Residents Affected - Some On July 3, 2023, at 11:55 PM the resident's bed alarm was sounding. Nursing staff entered the resident's room and observed resident the resident lying on floor. The resident's head was on floor and beyond the floor safety mat with blood present. A laceration above right eye brow observed with right orbital swelling. Laceration bleeding profusely. Pressure applied. Neurological assessment performed. No LOC. Baseline mentation, Awake, alert and oriented x 1. Affect flat. Assisted from floor to bed with assist of three for further assessment. Passive range of motion to bilateral upper and lower extremities at baseline. Laceration above right brow with continued bleeding. The physician was notified, 911 initiated. Verbal report given to Transfer to the emergency department for evaluation. A review of hospital documentation dated July 4, 2023 at 12:14 A.M. revealed a large hematoma to right eye with bleeding noted. The physician ordered a CT scan of the head. The CT scan as completed On July 4, 2023 and the report indicated that the resident had: 1. Small acute on chronic bilateral parietal subdural hematomas left larger than right. 2. Left frontal subdural hematoma is slightly smaller than on prior the right frontal subdural hematoma is slightly larger. 3. Right frontal scalp hematoma. 4. Chronic changes as described The residents laceration was closed with 4 sutures and he was transported back to the facility. Current interventions, which were ineffective in prevent multiple falls and injuries, were to remain in place upon return to the facility. The facility failed to provide effective safety interventions and sufficient and timely staff supervision, at the level and frequency required, to prevent multiple falls for a resident at risk for falls, with known unsafe behaviors and a history of falls. 28 Pa Code 211.12 (d)(5) Nursing services 395288 Page 5 of 8 395288 09/07/2023 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of five residents sampled (Resident 1). Residents Affected - Few Findings included: A review of Resident 1's clinical record revealed a physician order dated August 15, 2023, to obtain a urinalysis and culture and sensitivity to rule out urinary tract infection. A review of a laboratory report for a urinalysis dated August 16, 2023, revealed the results as abnormal with blood, protein and bacteria in the sample. A physician's order dated August 16, 2023, was noted for Cephalexin 500 mg (an antibiotic medication) by mouth every 12 hours for 7 days for urinary tract infection. There was no physician/prescribed documentation of the clinical necessity of initiating antibiotic therapy prior to the results of the culture and sensitivity. A review of the resident's medication administration record for the month of August 2023, revealed that the resident received 13 doses of Cephalexin medication prior to her discharge from the facility on July 22, 2023. During the survey, the Director of Nursing contacted the lab and confirmed that the lab never completed Resident 1's culture and sensitivity in response to the abnormal urinalysis dated August 16, 2023, and that the CRNP should have waited for the C & S report prior to ordering the antibiotic to ensure its efficacy in the treating the identified infectious organism. During an interview September 7, 2023 at 1 P.M., the Director of Nursing confirmed that the resident received multiple doses of the antibiotics without documented evidence of its clinical necessity. Refer F881 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.2 (d)(3) Medical Director 395288 Page 6 of 8 395288 09/07/2023 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and the facility's infection prevention and control program and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by one of five sampled residents (Resident 1). Residents Affected - Few Findings include: A review of the facility policy for Antibiotic Stewardship, dated as reviewed July 2023, revealed that to reduce a resident's risk of adverse drug reactions and preserve drug efficacy in the face of rising multi-drug resistant pathogens, the facility: -Ensures staff expertise to develop and manage the antibiotic stewardship program, improve antibiotic use and the frequency with which they are used, with a commitment to quality improvement. -Educate staff on the importance of appropriate antibiotic use, and implementing strategies to optimize the use of antibiotics. -monitors antibiotic prescribing-Antibiotic stewardship measurement is critical to identify opportunities for improvement and assess the impact of improvement efforts. A review of Resident 1's clinical record revealed a physician order dated August 15, 2023, to obtain a urinalysis and culture and sensitivity to rule out urinary tract infection. A review of a laboratory report for a urinalysis dated August 16, 2023, revealed the results as abnormal with blood, protein and bacteria in the sample. A physician's order dated August 16, 2023, was noted for Cephalexin 500 mg (an antibiotic medication) by mouth every 12 hours for 7 days for urinary tract infection. There was no physician/prescribed documentation of the clinical necessity of initiating antibiotic therapy prior to the results of the culture and sensitivity. A review of the resident's medication administration record for the month of August 2023, revealed that the resident received 13 doses of Cephalexin medication prior to her discharge from the facility on July 22, 2023. During the survey, the Director of Nursing contacted the lab and confirmed that the lab never completed Resident 1's culture and sensitivity in response to the abnormal urinalysis dated August 16, 2023, and that the CRNP should have waited for the C & S report prior to ordering the antibiotic to ensure its efficacy in the treating the identified infectious organism. During an interview September 7, 2023 at 1 P.M., the Director of Nursing confirmed that the resident received multiple doses of the antibiotics without documented evidence of its clinical necessity. There was no evidence at the time of the survey of a functioning antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use to prevent unnecessary antibiotic use. 395288 Page 7 of 8 395288 09/07/2023 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0881 Level of Harm - Minimal harm or potential for actual harm During an interview September 7, 2023 at 1 P.M., the Director of Nursing confirmed that the resident received unnecessary doses of antibiotics and that the facility's antibiotic stewardship program was not implemented. Refer F757 Residents Affected - Few 28 Pa. Code 211.12 (d)(1)(2) Nursing services 28 Pa. Code 211.10 (a) Resident Care Policies 395288 Page 8 of 8