The facility has 36 patient assessments currently overdue, according to interviews with two MDS coordinators during a December 17th federal inspection.
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No staff member could explain how she got the scratches on her left arm.
The nurse, identified as RN #1 in the December 22 inspection report, had worked at Storybrook Care & Rehabilitation for less than two months.
The violation came to light during a complaint investigation triggered by a serious injury.
The failure to report extended across multiple levels of staff.
That is what federal inspectors found when they visited St Sophia Health & Rehabilitation Center on December 31, 2025.
The resident, identified as R1 in inspection records, was admitted with diabetes, acute and chronic respiratory failure, and a tracheostomy.
The citation was tagged at Immediate Jeopardy, the most serious level of harm federal inspectors can assign.
She had watched members file complaint after complaint at their monthly meetings.
The certified nursing assistant assigned to Resident #3 approached the nursing desk and reported the person was missing from their room.
The resident required the special precautions due to an ileostomy, open surgical wound, and open pressure ulcers.
But the Administrator made clear that justification was irrelevant.