All citations for St Sophia Health & Rehabilitation Center

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to St Sophia Health & Rehabilitation Center

Last standard health inspection on record

January 28, 2025

Showing 51 to 75 of 116 citations

  1. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  2. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  3. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  4. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  5. No harm, with potential for more than minimal harm

    Observe each nurse aide's job performance and give regular training.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0730, Nursing and Physician Services Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  6. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  7. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0758, Pharmacy Service Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  8. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  9. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  10. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0849, Administration Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  11. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  12. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  13. No harm, with potential for more than minimal harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  14. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    A waiver was granted (November 17, 2019).

  15. No harm, with potential for more than minimal harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  16. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 17, 2019. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 25, 2019).

  17. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of May 1, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 1, 2026).

  18. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of April 1, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 1, 2026).

  19. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 5, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 28, 2026).

  20. No harm, with potential for more than minimal harm

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0607, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 5, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 28, 2026).

  21. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of March 5, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 28, 2026).

  22. No harm, with potential for more than minimal harm

    Provide safe, appropriate pain management for a resident who requires such services.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of March 5, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 28, 2026).

  23. No harm, with potential for more than minimal harm

    Allow residents to self-administer drugs if determined clinically appropriate.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0554, Resident Rights Deficiencies. Inspection of February 26, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 20, 2026).

  24. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of January 22, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 23, 2026).

  25. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of January 22, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 23, 2026).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.