Inspection Reports for
Sapphire Nursing and Rehab at Goshen
46 Harriman Drive, Goshen, NY, 10924
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 16, 2025
Visit Reason
The inspection was a recertification survey conducted from April 10 to April 16, 2025, to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in updating comprehensive care plans to reflect changes in resident condition and comfort care status, maintaining proper food safety standards including kitchen floor conditions and staff hygiene, and implementing an effective infection prevention and control program with adequate infection surveillance documentation.
Deficiencies (3)
10 NYCRR 415.11(c)(2)(i-iii) The facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after a change in condition and conversion to comfort care for Resident #113. The care plan did not reflect the resident's decline or comfort care status.
10 NYCRR 415.14(h) The facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards. The kitchen had damaged tile and linoleum flooring and staff did not wear hairnets to prevent hair contamination.
10 NYCRR 415.19(b)(4) The facility did not maintain an infection prevention and control program designed to prevent communicable diseases. Infection surveillance reports lacked documentation of infection onset dates, signs and symptoms, laboratory results, isolation, and outbreak potential.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager #2 | Licensed Practical Nurse Unit Manager | Interviewed regarding Resident #113's care plan updates and condition changes. |
| Director of Social Work | Director of Social Work | Interviewed about interdisciplinary care plan meetings and updates for Resident #113. |
| Social Worker #1 | Social Worker | Interviewed about interdisciplinary care plan meetings and updates for Resident #113. |
| Director of Nursing | Director of Nursing | Interviewed about care plan initiation and updates for Resident #113 and infection control program. |
| Food Service Director | Director of Food Service | Interviewed about food safety practices and staff hygiene compliance. |
| Director of Maintenance/Housekeeping | Director of Maintenance/Housekeeping | Interviewed about kitchen equipment and floor inspections. |
| Assistant Director of Nursing Infection Preventionist | Assistant Director of Nursing Infection Preventionist | Interviewed about infection surveillance and infection control program. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Apr 16, 2025
Visit Reason
Inspection identified multiple standard health and life safety code deficiencies including care plan timing, food sanitation, infection control, exit signage, HVAC, sprinkler system maintenance, and means of egress issues. All deficiencies were corrected by June 9, 2025.
Findings
Inspection identified multiple standard health and life safety code deficiencies including care plan timing, food sanitation, infection control, exit signage, HVAC, sprinkler system maintenance, and means of egress issues. All deficiencies were corrected by June 9, 2025.
Deficiencies (9)
Care plan timing and revision
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Exit signage
Hvac
Illumination of means of egress
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Standards of construction for new existing nh
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 10, 2024
Visit Reason
Inspection found isolated standard health deficiencies related to bowel/bladder incontinence, catheter UTI, and physician visit documentation. All deficiencies were corrected by February 3, 2025.
Findings
Inspection found isolated standard health deficiencies related to bowel/bladder incontinence, catheter UTI, and physician visit documentation. All deficiencies were corrected by February 3, 2025.
Deficiencies (2)
Bowel/bladder incontinence, catheter, uti
Physician visits - review care/notes/order
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 10, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with catheter care and physician review of residents with Foley catheters, focusing on appropriate catheter removal and medical oversight.
Findings
The facility failed to ensure that residents admitted with indwelling Foley catheters were assessed for catheter removal as soon as possible, and the attending physician did not adequately review or document the appropriateness of continued catheter use for the residents reviewed.
Deficiencies (2)
F 0690: The facility did not assess or trial removal of Foley catheters for 2 of 3 residents admitted with catheters, lacking documentation of clinical indications or voiding trials as per facility policy.
F 0711: The attending physician did not review or document the appropriateness of continued Foley catheter use during required visits for 2 residents, with catheter status incorrectly documented as not applicable.
Report Facts
Residents reviewed for indwelling catheters: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Attending Physician #1 | Attending Physician | Named in findings regarding failure to review and document Foley catheter appropriateness |
| Licensed Practical Nurse #2 | Unit 2 Manager | Provided information on Foley catheter removal protocols and voiding trials |
| Director of Nursing | Provided information on physician review process for Foley catheter discontinuation |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 7, 2023
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements and the facility's adherence to care standards.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, providing appropriate treatment and care for pressure ulcers and skin conditions, ensuring accident hazard prevention and supervision, and maintaining adequate nursing staff levels to meet resident needs.
Deficiencies (4)
F 0584: The facility failed to maintain a safe, clean, and homelike environment with window curtains hanging off tracks, peeling and chipped wall paint, damaged sheet rock, and dirty/stained bed mattresses observed on 3 units.
F 0684: The facility did not provide appropriate treatment and care for residents with pressure ulcers and skin conditions, including failure to apply bilateral heel protectors for Resident #24 and lack of routine wound assessments for Resident #65.
F 0689: The facility failed to ensure accident hazard prevention and adequate supervision during meals for Resident #60, who was not provided liquids in the prescribed nectar thickened consistency and was unsupervised during meals.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs, with staffing below minimum requirements on multiple days and residents and staff reporting inadequate staffing and resulting care delays.
Report Facts
Deficiencies cited: 4
Resident care units reviewed: 3
Dates of observation: Observations conducted between 2023-01-31 and 2023-02-07.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager (RNUM #1) | Registered Nurse Unit Manager | Named in findings related to maintenance reporting and pressure ulcer care. |
| Certified Nursing Assistant (CNA #2) | Certified Nursing Assistant | Named in findings related to mattress condition and wound care. |
| Certified Nursing Assistant (CNA #3) | Certified Nursing Assistant | Named in findings related to maintenance reporting. |
| Licensed Practical Nurse (LPN #2) | Licensed Practical Nurse | Named in wound care observation and staffing interview. |
| Licensed Practical Nurse (LPN #3) | Licensed Practical Nurse | Named in staffing interview. |
| Registered Nurse (RN #2) | Registered Nurse | Named in staffing interview. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in staffing interview. |
| Administrator | Administrator | Named in staffing interview. |
| Director of Nursing (DON) | Director of Nursing | Named in staffing interview. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Feb 7, 2023
Visit Reason
Inspection revealed multiple standard health and life safety code deficiencies including care plan timing, accident hazards, quality of care, environment, nursing staff sufficiency, cooking facilities, EP testing, means of egress, physical environment, fire extinguishers, sprinkler system maintenance, and smoke barrier issues. Some deficiencies were corrected by March-April 2023; others remained uncorrected at time of report.
Findings
Inspection revealed multiple standard health and life safety code deficiencies including care plan timing, accident hazards, quality of care, environment, nursing staff sufficiency, cooking facilities, EP testing, means of egress, physical environment, fire extinguishers, sprinkler system maintenance, and smoke barrier issues. Some deficiencies were corrected by March-April 2023; others remained uncorrected at time of report.
Deficiencies (14)
Care plan timing and revision
Free of accident hazards/supervision/devices
Quality of care
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Cooking facilities
Ep testing requirements
Illumination of means of egress
Means of egress - general
Physical environment
Portable fire extinguishers
Sprinkler system - maintenance and testing
Standards of construction for new existing nh
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Dec 10, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of hospital transfers, incomplete implementation of care plans for positioning devices and nutrition, inadequate wound care and treatment orders, improper use of psychotropic medications without non-pharmacological interventions, improper food cooling procedures, and failure to follow proper hand hygiene during wound care.
Deficiencies (8)
F 0623: The facility did not ensure written notification was sent to families and the ombudsman regarding resident transfers to the hospital for 2 residents.
F 0656: The facility failed to implement care plan interventions for wheelchair positioning devices for Resident #75, resulting in improper positioning.
F 0657: The facility did not review, revise, or update the nutrition care plan to address significant weight loss for Resident #82.
F 0684: The facility failed to provide appropriate treatment and care for Resident #55's left lower extremity deep tissue injuries due to missing physician orders.
F 0692: The facility did not ensure acceptable nutritional status was maintained for Resident #82, who experienced significant weight loss without dietary intervention.
F 0758: The facility did not ensure non-pharmacological interventions were attempted prior to initiating antipsychotic medication for Resident #9, and lacked documentation supporting ongoing use.
F 0812: The facility failed to implement proper cooling procedures for cooked foods, lacking temperature logs to verify safe cooling.
F 0880: The facility did not ensure proper hand hygiene was followed during wound care treatment for Resident #55, as observed with the Director of Nursing.
Report Facts
Weight loss: 56.8
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 0.5
Occupational Therapy minutes: 155
Food fluid intake: 120
Food fluid intake: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in wound care hand hygiene observation and interviews regarding notification and care plan deficiencies. |
| Registered Nurse Manager | Registered Nurse Manager | Interviewed regarding psychotropic medication use and care plan implementation. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding wound care treatment orders for Resident #55. |
| Food Service Director | Food Service Director | Interviewed regarding food cooling procedures and lack of cooling logs. |
| Consulting Registered Dietitian | Registered Dietitian | Interviewed regarding nutrition care plan and documentation for Resident #82. |
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