Sapphire Rehabilitation And Care Center
SAPPHIRE REHABILITATION AND CARE CENTER in COLUMBUS, OH — inspection on September 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 09/03/25 at 1:33 P.M., CNP #425 revealed she had not been safety notified immediately on 08/12/25 when Resident #23 left the facility. CNP #425 was later told Resident #23 had left the facility and would not be returning.
During an interview on 09/08/25 at 12:39
verified the resident's medical record contained no documentation supporting the resident verbalized behaviors to support him wanting to leave against medical advice.
The DON verified the facility considered the resident leaving the facility an AMA discharge because the resident did not return when he left.
During an interview on 09/11/25 at 10:20 A.M., Regional Nurse #264 stated Resident #23 had lost his housing and the facility did not know where the resident went when he left the faciity on [DATE].
During an interview on 09/11/25 at 10:20 A.M., LNHA #271, the DON, and Regional Nurse #264 revealed they were unable to provide information as to why the police, APS, Ombudsman and/or the resident's female friend were not notified when Resident #23 left the faciity on [DATE].
Lastly, the DON and Regional Nurse #264 verified Resident #23 was alert and oriented but made unsafe decisions when he wanted alcohol.An attempt to reach the resident's physician (Physician #450) was made on 09/11/25 at 10:48 A.M.
The attempt was unsuccessful. A message was left asking the physician to return the call; however, no return call was received.Further review of the medical record revealed no AMA form located within the medical record regarding the resident requesting to leave the facility AMA, no assessment of the resident's ability to safely leave the facility due to potential decision-making impairment related to alcohol use, no communication or attempts to contact the hospital regarding the resident's status and no behaviors documented.
Facility staff continued to document through 08/15/25 the resident remained hospitalized (no hospital identified) with no mention the resident had refused to sign an AMA form and left the facility or make mention the resident had discharged from the facility.
The facility policy titled Resident Leave of Absence, dated 12/2024, revealed that all residents leaving the facility must have orders for supervised or unsupervised leave of absence.
Residents leaving the facility on leave of absence must sign out when leaving.
Prior to opening the door to allow a resident to leave, the nurse would verify the leave of absence order and would communicate the leave of absence with the receptionist.
Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once.
The nurse would document in a progress note the time the resident leaves the facility and if known, the purpose.
Review of the Facility Assessment Tool dated 07/31/25 revealed the number/average or range of residents with behavioral health needs was four to five residents, and those with active or current substance use disorders were four to five residents.
The assessment revealed the facility managed the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder, and other psychiatric diagnoses, intellectual or developmental disability.
Emotional support and mental well-being and support with helpful coping mechanisms would be provided.
The facility would identify hazards and risks for residents.
Behavioral and mental health providers were available to provide services to residents.This deficiency represents noncompliance investigated under Complaint Number 2596080.
365950 09/22/2025
Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220
Review of the census revealed Resident #3 was out to the hospital on [DATE] and returned to the facility on [DATE].
An interview on 08/28/25 at 2:13 P.M.
Director of Nursing (DON) verified Resident #3 had not been provided with a bed hold notification when Resident #3 went to the hospital on [DATE] and 05/25/25.
An interview on 09/02/25 at 10:49 A.M. Resident #3 stated she was told once that she had only nine days for her room to be held. Resident #3 verified she was not given a formal bed hold notification.
Review of the policy titled Bed-Holds and Returns, revised March 2017, revealed that prior to transfers residents or resident representatives would be informed in writing of the bed-hold and return policy.
Review of the policy titled Facility Initiated Transfers and Discharge Notice, dated December 2024, revealed that in emergencies the resident and their representative would be notified as soon as possible.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.