St Sophia Health & Rehab: Care Plan Failures - MO
Those care plans didn't exist, or weren't current, or were missing the details that made them useful.
The deficiency, cited under F0656 and classified as having the potential for actual harm, covered some residents at the facility. Inspectors found that care plans for residents on dialysis lacked physician orders and failed to document the location of treatment, the scheduled days, and the resident's chair time. Activities of daily living needs, the assistance residents require for bathing, dressing, eating, mobility, were also found to be inaccurate or out of date.
The administrator and director of nursing, identified in the inspection report only as P.M., confirmed the failures directly. They told inspectors they expected staff to be knowledgeable of and to follow facility policies. They expected care plans to be accurate and up to date. They said so plainly, in the language of people who understood what was supposed to happen and acknowledged it had not.
Dialysis is not a minor scheduling matter. Residents who receive it typically go three times a week, often to an off-site location, and the treatment takes several hours. A care plan that doesn't reflect where a resident goes, or when, or how long they are gone, leaves gaps that can affect every other aspect of that person's care. Staff covering a shift who don't know a resident is off-site for dialysis may not account for their absence. Staff who don't know a resident's chair time can't coordinate meals, medications, or other scheduled care around it.
The same logic applies to activities of daily living. A care plan that doesn't accurately reflect how much help a resident needs getting dressed, or whether they can feed themselves, or how they transfer from bed to wheelchair, is a plan that may not be followed, because the person following it doesn't have the right information.
St Sophia Health & Rehabilitation Center sits on Charbonier Road in Florissant, a suburb north of St. Louis. The complaint inspection that produced this citation was completed August 18, 2025.
The deficiency was rated at the lower end of the harm scale, potential for actual harm rather than actual harm, and the number of residents affected was listed as some. But the administrator's own words to inspectors made clear the standard the facility set for itself and did not meet. They expected the care plans to be accurate. They expected the staff to follow them. The record showed neither expectation was being fulfilled.
A plan of correction was required. For information on what the facility submitted, inspectors directed readers to contact the nursing home or the state survey agency directly.
What the inspection report does not say is whether any resident on dialysis missed a treatment, received it late, or experienced a gap in their daily care because the information guiding their care was wrong. That question remains unanswered in the public record. The administrator and director of nursing said they expected better. The care plans said otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Sophia Health & Rehabilitation Center from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 16, 2026 · Our methodology
ST SOPHIA HEALTH & REHABILITATION CENTER in FLORISSANT, MO was cited for violations during a health inspection on August 18, 2025.
Those care plans didn't exist, or weren't current, or were missing the details that made them useful.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.