Sapphire Care And Rehab Center
Inspection Findings
F-Tag F0558
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2025-08-15.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0627
F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for
a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined the facility failed to demonstrate that a resident's discharge from the facility was appropriate and necessary, for one of three sampled residents (Resident 112).Findings include: Clinical record review revealed that Resident 112 was admitted to the facility on [DATE REDACTED], with diagnoses to include acute kidney failure (an abrupt decrease in kidney function, resulting in the retention of waste products) and unsteadiness on feet. Review of an entry Minimum Data Set Assessment (MDS a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated July 7, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 14 indicating she was cognitively intact. A
review of Resident 112's hospital discharge history and physical paperwork from July 7, 2025, revealed the resident had been hospitalized in part due to her inability to care for herself. Review of Resident 112's clinical record revealed the resident was discharged home from the facility on July 19, 2025. Information provided from the Area Agency on Aging revealed upon return home the resident had no food in her home that the only item in the refrigerator/freezer was ice cubes. A review of Resident 112's clinical record revealed social service notes dated July 18, 2025, indicating residents discharge planning had been discussed with the resident's family. However, there were no social service notes indicating how the family would assist the resident with acquiring food and other services to assist the resident in the transition to home, given the resident's prior difficulty in caring for herself. During an interview on August 14, 2025, at approximately 11:00 AM, the Director of Social Services (SS) confirmed Resident 112 was to be discharged to her home. The Director of SS was unable to provide documented evidence that Resident 112 would receive the required care and services to ensure a safe discharge to home. A physician discharge note dated July 19, 2025, indicated Resident 112 arrived at the facility after a hospitalization due to increased weakness and inability to care for herself, and was to be discharged home. The facility failed to demonstrate that the discharge was appropriate. During an interview with the Social Service Director on August 14, 2025, at 12:00 PM it was unable to provide documented evidence that Resident 112's discharge was safe and appropriate.28 Pa. Code 201.29(h) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee.
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
Event ID:
F-Tag F0641
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-08-15.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0684
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0686
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0688
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0688 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0689
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0692
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-08-15.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0755
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-08-15.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0761
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-15.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
F-Tag F0909
Federal health inspectors cited SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA for a deficiency under regulatory tag F-F0909 during a standard health inspection conducted on 2025-08-15.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of SAPPHIRE CARE AND REHAB CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-29.
SAPPHIRE CARE AND REHAB CENTER in EAST STROUDSBURG, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EAST STROUDSBURG, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SAPPHIRE CARE AND REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.