St Sophia Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at St Sophia Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 28, 2025

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #45), assessed to be at risk for aspiration, was served pureed meat and thickened liquids in accordance with physician's orders. The resident recently returned from a hospitalization after aspirating at the facility, resulting in aspiration pneumonia (an infection caused by inhaling something other than air into your lungs) for which he/she received intravenous antibiotics. The facility staff failed to monitor the resident in the dining room, as assessed in the Minimum Data Set (MDS), which showed the resident required supervision and touching assistance for eating. […]

• Immediate jeopardy, isolatedF689Jul 18, 2024

  See Event ID 6YPW12. Based on observation, interview and record review, the facility failed to provide protective oversight to one of three sampled residents identified by the facility as at risk for elopement. Resident #8, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia (a serious mental health condition that affects how people think, feel and behave) and was assessed to have moderate cognitive impairment. The resident had a known history of elopement and was admitted to the facility due to elopements while at home. During routine rounds, staff who were assigned to the resident failed to visibly check for confirmation of the resident's whereabouts. […]

• Immediate jeopardy, isolatedF689Jun 3, 2024

  Based on observation, interview and record review, the facility failed to provide protective oversight to one of three sampled residents identified by the facility as at risk for elopement. Resident #8, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia (a serious mental health condition that affects how people think, feel and behave) and was assessed to have moderate cognitive impairment. The resident had a known history of elopement and was admitted to the facility due to elopements while at home. During routine rounds, staff who were assigned to the resident failed to visibly check for confirmation of the resident's whereabouts. […]

• Immediate jeopardy, isolatedF689Jun 3, 2024

  Based on observation, interview and record review, the facility failed to provide protective oversight to one of three sampled residents identified by the facility as at risk for elopement. Resident #8, who resided on the facility's secured unit, had diagnoses of Alzheimer's disease and schizophrenia (a serious mental health condition that affects how people think, feel and behave) and was assessed to have moderate cognitive impairment. The resident had a known history of elopement and was admitted to the facility due to elopements while at home. During routine rounds, staff who were assigned to the resident failed to visibly check for confirmation of the resident's whereabouts. […]

• Immediate jeopardy, isolatedF678Oct 18, 2023

  Based on observation, interview and record review, the facility failed to ensure staff who transport residents in the facility van were certified in Cardiopulmonary Resuscitation (CPR) for healthcare providers, when residents potentially requiring CPR were being transported. This affected one resident (Resident #10) who was a full code (CPR to be provided in the event the heart stops beating) observed to be transported in the facility van with staff who was not CPR certified. The census was 169. The Administrator was notified on [DATE] at 1:04 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. […]