Florissant Valley Health & Rehabilitation Center
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when the facility failed to follow physician orders for a new medication to treat nerve pain for 10 days after the resident returned from an appointment with the neurologist (physician who treats the nervous system). The sample size was 4. The census was 79.The administrator was notified on 10/29/25, of the past non-compliance. The administrator of the facility investigated immediately 10/12/25, in-serviced all staff on following up on resident outside appointments to ensure paperwork is received and reviewed when a resident returns from an appointment for new and or changed orders. Facility conducted a 100% audit of residents outside appointments for paperwork for new and/or changed orders and the Medical Director (MD) and resident representative notifications were completed on any missed orders. The past non-compliance was corrected on 10/17/25. Review of the facility's Physician Orders Policy, updated 9/28/22, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state & federal guidelines.-The Licensed Practical Nurse (LPN), Registered Nurse (RN), nursing administration and
the Director of Nursing (DON) are responsible to follow physician orders as written and clarify illegible or unclear orders prior to implementation. Review of Resident #1's electronic medical record (EMR) showed:-Moderately impaired cognition;-Diagnoses included Wernicke's encephalopathy (a severe neurological emergency caused by Vitamin B1 deficiency), muscle wasting and atrophy, diabetes, and vascular diseases;-A Neurology after visit summary, dated 10/2/25, showed start taking this medication: gabapentin (seizure medicine that can be used to treat nerve pain) 100 milligram (mg) capsule daily;-A nurse progress note dated 10/13/25, resident's family member approached nurses' station regarding the medication gabapentin. This nurse Informed him/her that an order for gabapentin was not on the resident medication list. Call placed to physician; new order received for gabapentin 100 mg daily. Call placed to pharmacy and medication ordered;-A physician order dated 10/13/25 for gabapentin 100 mg in the morning for nerve pain. During an interview with the Administrator and Interim DON on 10/28/25 at 2:40 P.M., they said they were aware of the resident not receiving ordered gabapentin until 10/13/25 due to facility not following up on resident outside appointment on 10/2/25 with the neurologist. They would have expected staff to have called the physician's office and request follow up paperwork since the resident did not return to the facility with the paperwork. 2644453
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
FLORISSANT VALLEY HEALTH & REHABILITATION CENTER in FLORISSANT, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FLORISSANT, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FLORISSANT VALLEY HEALTH & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.