Inspection·February 25, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to timely notify the resident's interested representative of a change in condition for one resident out of 20 sampled (Resident 19). Findings include: A review of the facility's policy Change in a Resident's Condition or Status last reviewed by the facility January 2025, indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status. A review of the clinical record revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), and hypertension (high blood pressure). The resident's clinical record identified an emergency contact as their designated representative. A quarterly Minimum Data Set assessment (MDS- standardized assessment completed at specific intervals to plan care) dated December 18, 2024, indicated the resident had a BIMS score of 12 (Brief Interview for Mental Status-a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). Nursing documentation on January 5, 2025, at 2:22 PM, stated that Resident 19 activated their call light and reported feeling unwell, stating, I feel like throwing up and I do not feel good. The resident's temperature was 97.2°F, and a COVID-19 test was administered, resulting in a positive test. Nursing documentation dated January 5, 2025, at 3:59 PM revealed the resident is her own RR (resident representative) and aware of her positive covid test and the physician was made aware of the positive covid result. Continued review of nursing documentation dated January 15, 2025, at 1:27 PM, ten (10) days after Resident 19 tested positive for covid, indicated that the family was updated on the resident's condition and test result on January 7, 2025. Interview with the [NAME] President of Operations on February 25, 2025, at 10:15 AM confirmed that a BIMS score of 12 indicates moderate cognitive impairment and that facility policy requires the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395288 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 02/25/2025 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)