St Sophia Health & Rehab: Weight Loss Ignored - MO
Nobody flagged the weight loss at morning meetings. Nobody contacted the physician about putting interventions in place. The regional dietitian was never notified. When a state inspector arrived on October 30, 2025, and started asking questions, the Regional Nurse Consultant said he or she was not familiar with the resident at all.
The facility's own physician laid out what should have happened. During an interview that morning, Physician D said the resident eats well in general but will refuse meals at times and has an unstable blood sugar. The physician said the facility should have identified the weight loss and put interventions in place, and that the registered dietitian should have been notified. The physician was not describing a complex clinical puzzle. The physician was describing a gap in basic monitoring.
The Regional Nurse Consultant, interviewed the same day, said the same thing from a different angle. The facility should have been reviewing the resident's weights during the morning stand-up meeting. From there, staff should have contacted the registered dietitian and the resident's physician to get something in place before the weight loss continued. The administrator was in the room and agreed.
That agreement did not come with an explanation of why none of it had happened.
When inspectors returned on November 6, they spoke with the Director of Nursing. The DON said he or she had only been with the facility for about four days. The charge nurse and the unit manager, the DON explained, should have been reviewing the resident's hospital records for any orders or recommendations that came back with the resident after each hospitalization. The DON said that he or she, or the assistant director of nursing, would review those hospital records the following day as a follow-up. Meal consumption, the DON added, should be documented in the electronic health record by the charge nurse. The administrator was present again and agreed again.
The resident had been going back and forth to the hospital. That detail, offered by the physician, sits at the center of the failure here. Each hospitalization produces records, orders, and recommendations. Those records were apparently not being reviewed in any systematic way when the resident returned. A resident with an unstable blood sugar who refuses meals intermittently and has lost enough weight to trigger a complaint inspection is not a resident who can be monitored passively. The physician knew it. The Regional Nurse Consultant knew it. The new Director of Nursing knew it within her first week on the job.
The charge nurses and unit managers who were present during the weeks and months before the inspection apparently did not act on it, or did not recognize it as something requiring action.
CMS rated the violation at a level of minimal harm or potential for actual harm, meaning inspectors determined the resident had not yet suffered serious injury from the lapse. The citation covers a few residents.
St. Sophia Health and Rehabilitation Center is located in Florissant, in St. Louis County. The inspection was a complaint survey, meaning someone, a resident, a family member, or a staff member, had contacted regulators before inspectors walked through the door.
The DON, four days into the job, said the follow-up review of hospital records would happen the next day. Whether it did is not reflected in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Sophia Health & Rehabilitation Center from 2025-10-30 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
ST SOPHIA HEALTH & REHABILITATION CENTER in FLORISSANT, MO was cited for violations during a health inspection on October 30, 2025.
Nobody flagged the weight loss at morning meetings.
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.