Sapphire Rehab: Missing Resident Immediate Jeopardy - OH
The man, identified in federal inspection records as Resident 23, left the facility on a date redacted from the report. He did not return. No one called the police. No one called Adult Protective Services. No one called the ombudsman. No one called the female friend listed in his file. The facility's nurse practitioner was not notified that day. His physician was never reached at all.
What the medical record did show, through August 15, was notation after notation stating the resident remained hospitalized, with no hospital named, no explanation of why he had left, no mention that he had refused to sign anything, and no mention that anyone considered him missing.
Federal inspectors cited the facility for immediate jeopardy, the most serious classification available under Medicare oversight, meaning the failure placed the resident at risk of serious harm or death.
The facility is disputing the citation.
The director of nursing, interviewed September 8, confirmed the resident left at 6:45 a.m. and did not return. She confirmed his medical record contained no documentation that he had ever said he wanted to leave. There were no documented behaviors pointing toward an against-medical-advice departure. The facility nevertheless classified his absence as an AMA discharge, she acknowledged, simply because he did not come back.
That is not how an AMA discharge works. An AMA discharge requires a resident to state they want to leave, to be assessed, and to sign a form. There was no form. There was no assessment. There was no statement. The facility's own policy required a leave-of-absence order before any resident walked out the door, required the resident to sign out, and required a nurse to verify the order before the door was opened. None of that happened either.
The nurse practitioner, identified as CNP 425, told inspectors she learned later that Resident 23 had left and would not be returning. She had not been notified on the morning he walked out.
The regional nurse, identified as Regional Nurse 264, and the licensed nursing home administrator, identified as LNHA 271, sat together with the director of nursing during an interview on September 11 and could not explain why no one had contacted police, APS, the ombudsman, or the resident's friend when he left. They had no answer.
What they did know was this: Resident 23 was alert and oriented. He also made unsafe decisions when he wanted alcohol. The facility's own assessment tool, dated July 31, documented that between four and five residents at Sapphire had active or current substance use disorders. The facility had committed, on paper, to identifying hazards and risks for those residents, to providing emotional support, and to connecting them with behavioral health providers. The assessment named anxiety, cognitive impairment, depression, trauma, and psychiatric diagnoses as conditions the facility managed.
Resident 23 fit squarely inside that population. His decision-making was understood to be impaired under specific circumstances. No one assessed whether those circumstances applied when he walked out the door at 6:45 a.m.
The Social Services Director, identified as SSD 312, told inspectors she had been unable to locate the resident at all. What she eventually pieced together, through secondhand information, was that after leaving the facility he had gone to one hospital, been discharged to the community, and then ended up at a different hospital. The regional nurse confirmed to inspectors that Resident 23 had lost his housing before his admission to Sapphire. When he left, the facility did not know where he went.
A man with no housing, a known vulnerability to alcohol-related decision-making, and no signed discharge paperwork walked out of a nursing facility and disappeared into a city, and the people responsible for his care responded by writing "hospitalized" in his chart for three days.
Inspectors attempted to reach his physician, identified as Physician 450, on September 11 at 10:48 in the morning. A message was left. No call came back.
The inspection was conducted as a complaint investigation, complaint number 2596080, and concluded September 22, 2025. The facility, located at 1605 Northwest Professional Plaza, is contesting the immediate jeopardy finding.
What is not in dispute is what the record shows: a man walked out, the people who were supposed to protect him did not act, and for three days his chart described a hospitalization that no one could name, at a hospital no one could identify, for a resident no one could find.
The Social Services Director was still trying to locate him when inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sapphire Rehabilitation and Care Center from 2025-09-22 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
SAPPHIRE REHABILITATION AND CARE CENTER in COLUMBUS, OH was cited for immediate jeopardy violations during a health inspection on September 22, 2025.
The man, identified in federal inspection records as Resident 23, left the facility on a date redacted from the report.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.