Inspection Results » St Sophia Health & Rehabilitation Center

Health Inspection on April 20, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-06-04)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-05-25)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-05-25)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-05-25)
   • 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. (Corrected 2018-05-25)
   • Provide activities to meet all resident's needs. (Corrected 2018-05-25)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-05-25)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-05-25)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-05-25)
   • 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. (Corrected 2018-05-25)
   • 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. (Corrected 2018-05-25)
   • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Corrected 2018-05-25)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-05-25)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-05-25)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-06-04)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-05-25)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-05-25)
   • 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. (Corrected 2018-05-25)