CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for St Sophia Health and Rehabilitation Center
View the most recent health deficiencies and inspection results for St Sophia Health and Rehabilitation Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for St Sophia Health and Rehabilitation Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2026-04-01 | 2026-04-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2026-03-05 | 2026-03-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2026-03-05 | 2026-03-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2026-03-05 | 2026-03-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-03-05 | 2026-03-28 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2026-02-26 | 2026-03-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2026-02-26 | 2026-02-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-12-31 | 2026-01-29 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-12-31 | 2026-01-29 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2025-12-31 | 2026-01-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-01-22 | 2026-01-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2026-01-22 | 2026-01-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-01-22 | 2026-01-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-10-30 | 2025-11-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-10-30 | 2025-11-18 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2025-11-06 | 2025-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-11-06 | 2025-11-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-10-03 | 2025-11-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-10-03 | 2025-11-07 | Y |
| 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. | Health | 2025-10-03 | 2025-11-07 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2025-10-03 | 2025-11-07 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-08-18 | 2025-09-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-08-18 | 2025-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-18 | 2025-09-24 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-08-18 | 2025-09-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-05-21 | 2025-06-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-05-21 | 2025-06-17 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-01-28 | 2025-03-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-01-28 | 2025-03-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-01-28 | 2025-02-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-01-28 | 2025-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-28 | 2025-02-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-01-28 | 2025-02-27 | N |
| 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. | Health | 2025-01-28 | 2025-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-01-28 | 2025-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-01-28 | 2025-02-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2025-01-28 | 2025-02-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-01-28 | 2025-02-27 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-01-28 | 2025-02-27 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2025-01-28 | 2025-02-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-01-28 | 2025-02-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-01-28 | 2025-02-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-01-28 | 2025-02-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-01-28 | 2025-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-01-28 | 2025-02-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-01-28 | 2025-02-27 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2025-01-28 | 2025-02-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-01-28 | 2025-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-01-28 | 2025-02-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-01-28 | 2025-02-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-09-27 | 2024-12-12 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-09-27 | 2024-12-12 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-09-27 | 2024-12-12 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-11-08 | 2024-12-12 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-11-08 | 2024-12-12 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-11-08 | 2024-12-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-27 | 2024-10-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-03 | 2024-07-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-18 | 2024-07-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-18 | 2023-11-08 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-18 | 2023-09-29 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-25 | 2023-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-25 | 2023-07-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-25 | 2023-07-06 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-05-25 | 2023-07-06 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-05-25 | 2023-07-06 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-25 | 2023-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-07-06 | N |
| 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. | Health | 2023-05-25 | 2023-07-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-18 | 2023-06-13 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-17 | 2019-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-17 | 2019-06-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-17 | 2019-06-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-17 | 2019-06-25 | N |
| 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. | Health | 2019-05-17 | 2019-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-17 | 2019-06-25 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-05-17 | 2019-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-17 | 2019-06-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-17 | 2019-06-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-17 | 2019-06-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-17 | 2019-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-17 | 2019-06-25 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-05-17 | 2019-06-25 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-05-17 | 2019-06-25 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-05-17 | 2019-06-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-05-17 | 2019-06-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-17 | 2019-06-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-17 | 2019-06-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-01-28 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-01-28 | Not Fixed | N |