Health 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 Page 1 of 2 395288 395288 02/25/2025 Sapphire Care and Rehab Center 221 East Brown Street East Stroudsburg, PA 18301

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's emergency contact to be notified within 24 hours of a significant change in condition, such as an illness or a positive test result. The VP confirmed there was no documentation of timely notification. Interview with the facility's Infection Preventionist (IP) on February 25, 2025, at 12:30 PM confirmed that Resident 19 tested positive for COVID-19 on January 5, 2025, and that there was no documented evidence that the resident's emergency contact was notified in a timely manner. Interview with Resident 19's emergency contact on February 25, 2025, at 6:00 PM revealed the facility never contacted her regarding the resident's positive COVID-19 diagnosis. The emergency contact stated that she learned about the resident's condition only through a phone conversation with the resident, rather than from facility staff. There was no documented evidence the resident's emergency contact was timely notified of the residents change in condition and positive covid test result as required by the facility policy. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services 395288 Page 2 of 2