Cycle 1
Health 2025-01-28 · Fire 2025-01-28
34 health deficiencies
Top issue: Resident Rights (11 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Florissant, MO
St Sophia Health & Rehabilitation Center
1-star overall rating with 1-star inspections with $87,273 in total fines with 34 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
936 Charbonier Road, Florissant, MO
(314) 831-4800
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
167
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mgm Healthcare
Operator or chain grouping
Approved since
1975-03-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.96
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.87
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.45
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
2.47
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,329
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.58
Baseline 20.43% · Performance 18.84% · Measure score 5.58 · Achievement 5.58 · Improvement 4.16
Healthcare-associated infections
4.74
Baseline 8.16% · Performance 6.50% · Measure score 4.74 · Achievement 4.46 · Improvement 4.74
Total nurse turnover
2.99
Baseline 79.25% · Performance 60.27% · Measure score 2.99 · Achievement 0.83 · Improvement 2.99
Adjusted total nurse staffing
0
Baseline 2.84 hours · Performance 2.44 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.45% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 19.66% · Lower 95% interval 9% |
| Discharge to community | 37.48% |
50.57%
13.1 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 20% · Lower 95% interval 27.59% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 26.67% |
95.27%
68.6 pts worse
|
Numerator 16 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 26.92% |
53.69%
26.8 pts worse
|
Numerator 7 · Denominator 26 |
| Discharge mobility score | 38.46% |
50.94%
12.5 pts worse
|
Numerator 10 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 3 · Denominator 60 · Adjusted rate 4.23% |
| Healthcare-associated infections requiring hospitalization | 6.5% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 6.35% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 24.52% |
42%
17.5 pts worse
|
Numerator 64 · Denominator 261 |
| Discharge function score | 34.62% |
56.45%
21.8 pts worse
|
Numerator 9 · Denominator 26 |
| Transfer of health information to provider | 30% |
95.95%
66 pts worse
|
Numerator 9 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.68% |
25.2%
15.5 pts worse
|
Numerator 3 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 17.8% |
84.8%
67 pts worse
|
93.4%
75.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 19.7% · Q3 10.4% · Q4 10.1% · 4Q avg 17.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 50.9% |
90.9%
40 pts worse
|
95.5%
44.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 50.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
4.1%
3.6 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 98.7% |
14.7%
84 pts worse
|
11.4%
87.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 97.8% · Q3 100.0% · Q4 99.2% · 4Q avg 98.7% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
5.5%
4.6 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.5% · Q4 0.7% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
25.3%
11.5 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 16.9% · Q3 16.1% · Q4 13.5% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
25.0%
0.5 pts better
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 23.6% · Q3 18.9% · Q4 21.2% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.5% |
20.3%
14.8 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 5.2% · Q3 1.6% · Q4 1.5% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
19.8%
12.1 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 4.9% · Q3 3.0% · Q4 5.2% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.4%
1.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
18.1%
0.6 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 15.2% · Q3 18.0% · Q4 27.8% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.0%
2.1 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.9% · Q3 2.7% · Q4 3.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 6.0% |
66.4%
60.4 pts worse
|
81.7%
75.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 11.0% · Q3 3.6% · Q4 2.5% · 4Q avg 6.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
13.4%
2.6 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 15.3% · Expected 15.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.2%
1.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 9.5% |
63.5%
54 pts worse
|
79.7%
70.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 9.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
25.3%
4.8 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 44.4% · Expected 35.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
23 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-05-17 · Fire 2019-05-17
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-01-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
E · Potential for more than minimal harm
2025-01-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
E · Potential for more than minimal harm
2025-01-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-01-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-27
F · Potential for more than minimal harm
2023-05-25
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-05-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-05-25
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-05-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-05-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-05-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-06
E · Potential for more than minimal harm
2019-05-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-11-17
E · Potential for more than minimal harm
2019-05-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-23
D · Potential for more than minimal harm
2026-01-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-23
D · Potential for more than minimal harm
2026-01-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-12-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-29
D · Potential for more than minimal harm
2025-12-31
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-29
D · Potential for more than minimal harm
2025-12-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-29
D · Potential for more than minimal harm
2025-11-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-11-06
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-10-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-10-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-11-18
E · Potential for more than minimal harm
2025-10-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-10-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-10-03
F688 · Quality of Life and Care Deficiencies
Health
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 2025-11-07
D · Potential for more than minimal harm
2025-10-03
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-11-07
E · Potential for more than minimal harm
2025-08-18
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-08-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-08-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-08-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-05-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-21
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-17
J · Immediate jeopardy
2025-01-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-27
E · Potential for more than minimal harm
2025-01-28
F761 · Pharmacy Service Deficiencies
Health
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 2025-02-27
E · Potential for more than minimal harm
2025-01-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F620 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-11-08
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-08
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-08
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-09-27
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-09-27
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-27
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-12-12
J · Immediate jeopardy
2024-07-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-16
J · Immediate jeopardy
2023-10-18
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-09-29
J · Immediate jeopardy
2023-10-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-10-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-05-25
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F909 · Environmental Deficiencies
Health
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.
Corrected 2023-07-06
F · Potential for more than minimal harm
2019-05-17
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F761 · Pharmacy Service Deficiencies
Health
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 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F849 · Administration Deficiencies
Health
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 2019-06-25
E · Potential for more than minimal harm
2019-05-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-05-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-05-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-05-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-05-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-06-25
Penalties and ownership
What sits behind the stars
$51,630
2025-01-28
Fine
Fine · fine $51,630
Fine
$0
2025-01-28
Payment Denial
Payment Denial · denial start 2025-02-28 · 18 days
18 day denial
$14,053
2024-06-03
Fine
Fine · fine $14,053
Fine
$21,590
2023-10-18
Fine
Fine · fine $21,590
Fine
Ownership
St Sophia Realty LLC
5% Or Greater Indirect Ownership Interest · Organization
10-26 Nationwide Tr
5% Or Greater Direct Ownership Interest · Organization
Bienstock, Judah
5% Or Greater Direct Ownership Interest · Individual
3w Acquisitions LLC
5% Or Greater Direct Ownership Interest · Organization
Sofia Sunset Resources LLC
5% Or Greater Direct Ownership Interest · Organization
Bienstock, Judah
Corporate Director · Individual
Jeremias, Baruch
Corporate Officer · Individual
Johnston, Daniel
W-2 Managing Employee · Individual
Winter, Chaim
Operational/Managerial Control · Individual
Winter, Chaim
Corporate Officer · Individual
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