Inspection·October 11, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In room [ROOM NUMBER] there was a dried red substance on the privacy curtains. The molding next to the heating unit was chipped and and stained with a black substance. There was dried brown substance on the walls. Bed pans were observed stacked in the bathroom with a dried yellow urine like substance observed in one of the bed pans. Observations at 10:08 AM on October 11, 2023, of the Third Floor Nursing Unit revealed dried brown substances on the wall in the hallway. The wallpaper was ripped, torn, and peeling. In resident room [ROOM NUMBER], a dried brown substance was observed on the walls, a sticky yellow substance was observed on the bottom of the door frame with hair and dust stuck to it. The molding in the room was broken and there was a hole in the wall above the molding. A dried red substance was observed behind the bed. Dirt and debris was observed on the floor. In resident room [ROOM NUMBER] black scuff marks were observed on the walls. Dirt and debris was observed on the floor. Chips and gouges in the drywall were observed. Paint was observed peeling of the heating unit it the resident bathroom. Flaking rust was observed on the top of the bathroom heating unit. There was a strong smell of urine in the bathroom. The floor was sticky in resident room [ROOM NUMBER]. A dried brown substance was observed on the heating unit. There was a strong urine odor in the bathroom. The toilet paper holder was broken. A dried brown substance was observed on the toilet paper remaining in the holder. The caulking around the toilet was brown and cracked. There was a dried brown/yellow substance on the base of the toilet. The floor in resident room [ROOM NUMBER] was sticky. Stains were observed on the privacy curtains. The caulking around the toilet was brown and cracked. In resident room [ROOM NUMBER] the wallpaper was peeling wallpaper and black scuff were observed on the walls. A second observation of the above areas on October 11, 2023, at approximately 12:50 PM revealed the above findings remained and areas remained in the same condition as previously observed during the initial AM tour. An observation on October 11, 2023, at 1:40 PM of resident room [ROOM NUMBER] revealed a large dried crusty white substance on the mattress of bed 2 in the room. There was a brown substance and stains observed on the privacy curtains. Dried brown spots were observed on the wall. There was a whole in the wall and crumbling plaster observed behind bed 1. An interview with Resident 1 on October 11, 2023, at the time of the observation above revealed that the resident stated she is fed up with the facility. Resident 1 stated that the place is filthy and they do nothing about it. The resident reported that the dried vomit on the mattress on the second bed has been there as long as she has been in that room. The resident indicated she has never stayed in such a dirty place and she is at her wits end. Interview with the Nursing Home Administrator and Director of Nursing on October 11, 2023, at approximately 1:50 PM confirmed the facility is to be maintained daily to provide a clean and sanitary environment for the residents. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395288 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0917 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to provide clean mattresses, bed frames and functional furniture in resident rooms on three of three nursing units (First, Second, and Third Floor). Findings include: A tour of the facility's First Floor Nursing Unit on October 11, 2023, at 9:30 AM revealed in resident room [ROOM NUMBER] the bed frame of bed#2 was coated with an unknown dried substance and brown spots covering the bed frame. The fall mats next to bed were ripped and torn. A tour of the facility's Second Floor Nursing Unit on October 11, 2023, at 9:45 AM revealed in resident room [ROOM NUMBER] the mattress was cracked and flaking. Dried spots, stains, dirt and debris were observed on the bed frame. The mattress in resident room room [ROOM NUMBER] was dirty and an unknown dried substance and brown spots covering the bed frame. A tour of the facility's Third Floor Nursing Unit on October 11, 2023, at 10:08 AM revealed in the dressers in resident room [ROOM NUMBER] were chipped and top molding was broken off. The foot board of bed 2 had dried streaks of unknown substance were observed running down the foot board of the resident's bed. In resident room [ROOM NUMBER], the mattress was cracked and peeling. The dressers were chipped the top molding was broke off the dresser. The fall matt next to the first bed was cracked and torn. In resident room [ROOM NUMBER] the fall mats were cracked and torn. In room [ROOM NUMBER] mattresses on the first and second beds were cracked and flaking. The dressers in the room were chipped and had broken top molding. The second bed's bed frame had an unknown dried substance and brown spots covering the bed frame. There was also dirt and dust build up stuck to the bed frame in multiple places. An interview with the Nursing Home Administrator and Director of Nursing on October 11, 2023, at approximately 1:50 PM revealed that resident equipment should be maintained in a clean, safe and functional manner. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395288 If continuation sheet Page 3 of 3