Inspection·December 29, 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 a review of select facility policies, clinical record review, and staff and resident interviews, it was determined that the facility failed to promptly notify a resident's designated representative and power of attorney of a significant change in the resident's condition and new treatment orders, for one resident out of eight sampled (Resident 1). Findings include: A review of the facility's policy Change in a Resident's Condition or Status last reviewed by the facility July 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. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the lungs that results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs, making it difficult to breathe) and acute bronchitis (also known as a chest cold, is short-term inflammation of the bronchi (large and medium-sized airways) of the lungs and the most common symptom is a cough). The resident's clinical record identified a POA (power of attorney, a legal authorization that allows someone to make decisions or take actions on behalf of another person in financial, legal, or medical matters) and designated representative for emergency contact. A review of a quarterly Minimum Data Set assessment (MDS, a standardized assessment completed at specific intervals to plan care) dated October 17, 2025, indicated the resident had a BIMS score of 15 (Brief Interview for Mental Status, a tool used to assess the resident's attention, orientation, and the ability to register and recall new information. A score of 13-15 indications intact cognition). A review of the resident's clinical record revealed a physician/CRNP note completed by the facility's certified nurse practitioner on November 17, 2025, at 1:43 PM, documented an evaluation was completed due to Resident 1 coughing for two days and looked very tired. The documentation indicated a negative COVID-19 test and recorded vital signs, including oxygen saturation of 91 percent on room air. The assessment included acute cough with hypoxia (lower than normal oxygen levels in the blood), and new treatment orders were initiated, including a chest x-ray, supplemental oxygen via nasal cannula at two liters for oxygen saturation less than 93 percent, Mucinex 600 mg by mouth twice daily for seven days, albuterol as needed, and continued monitoring with instructions to notify the provider if symptoms worsened. The care plan was noted as discussed with nursing staff. Further review of Resident 1's clinical record failed to reveal documentation that the resident's responsible party or POA was notified of the resident's change in condition and the newly initiated treatment orders related to (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 12/29/2025 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)