Federal inspectors found St Sophia Health & Rehabilitation Center systematically failed to provide restorative services to residents who needed them. The facility's own staffing records showed the restorative aide was reassigned to floor duties seven out of 12 days between September 23 and October 3.
Resident #1 told inspectors the situation directly: "I used to receive restorative services, but I have not had any services in a long time." The resident could not recall when they last received the prescribed exercises and said they would like to get them again.
The resident's medical records showed significant mobility limitations. They required minimal assistance with daily activities, used a cane or walker, and had functional range of motion impairment on one side of their lower extremity. Despite being cognitively intact and able to walk 10 feet, they were not receiving the restorative therapy prescribed to maintain their function.
Three other residents faced the same neglect.
Resident #23 described a similar pattern during an October 1 interview. "I used to receive restorative services, and they would come down and walk with me two to three times a week," the resident said. "It has been a while since restorative therapy walked with me."
Like Resident #1, this person was cognitively intact and able to ambulate 10 feet with minimal assistance. They used a cane or walker and had range of motion impairment in their lower extremity. The physical therapist had specifically referred them for restorative services, but the prescribed walking sessions had stopped.
The facility's own documentation revealed the scope of the problem. Inspectors reviewed the restorative aide's binder and found therapy-developed plans for four residents requiring range of motion exercises three times per week. Yet these residents received restorative services only twice within the prior 10 days.
The restorative aide explained the impossible situation during a 7:00 AM interview on October 1. "I get pulled to the floor and there is no one to do restorative," the aide said. While any certified nursing assistant could perform range of motion exercises or stretching, "it doesn't always happen."
The aide emphasized the frequency of the problem: "I get pulled to the floor almost daily."
Physical therapy staff were fully aware their treatment plans were being ignored. During an October 2 interview, the physical therapist explained the clinical reasoning behind the prescribed care. The therapist wrote restorative plans for residents who were candidates based on comprehensive therapy evaluations across all disciplines.
For Resident #1 specifically, the therapist said, "Resident #1 was evaluated by therapy and referred to restorative for passive stretching exercises to hopefully prevent contracture."
But the therapist acknowledged the system was failing. "Therapy staff were aware of the restorative not getting done every day, and is aware restorative is not being done as ordered due to staffing issues."
The clinical stakes were clear. Without regular stretching and range of motion exercises, residents like Resident #1 faced increased risk of developing contractures - permanent muscle shortening that can severely limit mobility and cause pain.
Management acknowledged the program's complete breakdown. During an October 3 interview, the Director of Nursing made a stark admission about the facility's restorative program: "The restorative program needs revamped, started over, from the ground up."
The director agreed "that restorative is not always getting done as it should."
This was not a minor scheduling issue or occasional missed session. The facility had essentially abandoned a core component of rehabilitative care for residents who depended on it to maintain their mobility and independence.
The inspection found residents were prescribed specific therapeutic interventions - passive stretching to prevent contractures, walking exercises to maintain mobility, range of motion work to preserve function. Instead, they received sporadic attention when staffing allowed, which was less than half the time according to the facility's own records.
For residents already dealing with mobility limitations, cognitive challenges, or recovery from illness or injury, the loss of consistent restorative care represented a significant step backward in their quality of life and functional independence.
The failure affected residents across different levels of need - from those who could walk short distances with assistance to those requiring passive exercises to prevent further physical deterioration. All shared the same experience of promised care that simply did not materialize on a reliable basis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Sophia Health & Rehabilitation Center from 2025-10-03 including all violations, facility responses, and corrective action plans.
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