Deficiency Records for St Sophia Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for St Sophia Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-25 | 2023-07-24 | 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 |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-05-25 | 2023-07-06 | N |
| Ensure each resident receives an accurate assessment. | 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 medically-related social services to help each resident achieve the highest possible quality of life. | 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 |
| 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 | 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 | 2023-05-25 | 2023-07-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-25 | 2023-07-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-25 | 2023-07-06 | Y |
| 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 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-25 | 2023-07-06 | Y |
| 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 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Implement emergency and standby power systems. | 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 |
| 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 |
| Provide properly protected cooking facilities. | 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 |
| Inspect, test, and maintain automatic sprinkler 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 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 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 |
| 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-25 | 2023-07-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-20 | 2023-03-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-20 | 2023-03-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-03-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-20 | 2023-03-01 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-01-20 | 2023-03-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-20 | 2023-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-20 | 2023-03-01 | 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 | 2023-01-20 | 2023-03-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-20 | 2023-03-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-20 | 2023-03-01 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-20 | 2023-03-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-01-20 | 2023-03-01 | Y |
| Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. | Health | 2023-01-20 | 2023-03-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-26 | 2022-09-20 | Y |
| Provide appropriate foot care. | Health | 2022-08-26 | 2022-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-26 | 2022-09-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-26 | 2022-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-21 | 2022-09-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-21 | 2022-09-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-21 | 2022-09-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-21 | 2022-09-20 | Y |
| Provide appropriate foot care. | Health | 2022-06-21 | 2022-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-21 | 2022-09-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-21 | 2022-09-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-21 | 2022-07-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-29 | 2022-04-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-10 | 2022-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-10 | 2022-04-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-10 | 2022-04-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-13 | 2022-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-13 | 2022-04-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-13 | 2022-04-12 | Y |
| 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 | 2022-01-13 | 2022-03-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-09 | 2021-12-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-09 | 2021-12-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-09 | 2021-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-09 | 2021-12-14 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-11-09 | 2021-12-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-09 | 2021-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-29 | 2021-12-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-29 | 2021-12-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-29 | 2021-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-29 | 2021-12-14 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-09-29 | 2021-12-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-29 | 2021-12-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-29 | 2021-10-27 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-09-29 | 2021-10-27 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-09-29 | 2021-10-27 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-17 | 2019-11-17 | N |
| Honor the resident's right to manage his or her financial affairs. | 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 |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | 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 |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 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 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 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 |
| Provide safe, appropriate dialysis care/services 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 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 |
| Provide and implement an infection prevention and control program. | 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 |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-17 | 2019-06-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-04-20 | 2018-06-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-20 | 2018-06-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-20 | 2018-05-25 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-04-20 | 2018-05-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-20 | 2018-05-25 | 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 | 2018-04-20 | 2018-05-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-20 | 2018-05-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-20 | 2018-05-25 | N |
| Provide activities to meet all resident's needs. | Health | 2018-04-20 | 2018-05-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-20 | 2018-05-25 | N |
| 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 | 2018-04-20 | 2018-05-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-20 | 2018-05-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-20 | 2018-05-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-20 | 2018-05-25 | 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 | 2018-04-20 | 2018-05-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-20 | 2018-05-25 | 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 | 2018-04-20 | 2018-05-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-04-20 | 2018-05-25 | 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 | 2018-04-20 | 2018-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-20 | 2018-05-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-20 | 2018-05-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-04-20 | 2018-05-11 | N |
