St Sophia Health & Rehabilitation Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

requisitions for him to fix or any water temps from nursing staff or any other departments and he is unaware

the hot water temperatures were not in range. 21. Observation on 8/15/25 from 2:00 P.M. until 2:25 P.M., hot water temperatures were as follows when tested for 2 minutes using a digital thermometer. The Maintenance Director was present during the observations:-room [ROOM NUMBER], measured 97 degrees F;-room [ROOM NUMBER], measured 97.1 degrees F;-room [ROOM NUMBER], measured 97.3 degrees F;-room [ROOM NUMBER], measured 92.3 degrees F;-room [ROOM NUMBER], measured 92.1 degrees F. During an interview on 8/15/25 at 2:24 P.M., the Maintenance Director said the temperatures were not in the regulatory range. 22. During an interview on 8/18/25 at 12:26 P.M., the Maintenance Director said he had some rooms that were too hot, and he has been making adjustments to the mixing valve. He noticed the rooms were too hot when he went in to test water with the surveyor. The hot water ranged from 125 degrees F to 130 degrees F. The Maintenance Director said he had one room that was close to 140 degrees F but he went back and forth and kept adjusting the temperature. He said there is only one boiler per hallway and for the rooms to reach the actual temperature, some rooms the hot water has to run for at least four to five minutes for the temperatures to reach at least 105 degrees F. 23. During an

interview 8/18/25 at 1:10 P.M., the Director of Nurses (DON) said the Maintenance Director is responsible for monitoring the water temperatures and he does these three to four times a month and records findings

in the hot water temperature logbook. He does one hall a week and sometimes will bunch 300-400 hall, or if someone says it's not right, he will go and check it and document on the temperature log. The Maintenance Director should check all the rooms and if temperatures are not in regulated range expected, the Maintenance Director should adjust so they are in range. If they are not reaching the temperature in certain rooms, if too far away from the boiler, if too hot, or if a different situation, he needs to keep adjusting the water and notify the Administrator and the Regional Maintenance Director. In addition, the DON said she expected staff to put in a work order to maintenance if they suspect water temperatures are out of range.

She expected them to also check the water temperature with a thermometer if it feels out of range and should be adjusting or have maintenance adjust it. The DON expected the same protocol if residents voice concerns to nursing staff.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St Sophia Health & Rehabilitation Center

936 Charbonier Road Florissant, MO 63031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

P.M., the Administrator and DON said they expected the staff to be knowledgeable of and to follow the facility policies. They expected the resident care plans to be accurate and up to date. They expected if a resident was receiving dialysis services, the resident would have physician orders and a care plan that listed the location the resident was receiving dialysis, the days of the week the resident was to receive dialysis and the resident's chair time. They expected the ADL care that residents need to be accurate and up to date in the resident's care plan. 2577829

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St Sophia Health & Rehabilitation Center

936 Charbonier Road Florissant, MO 63031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurse giving them report or the previous CNA would give that information to him/her in report. During an

interview on 8/18/25 at 11:52 A.M., the Assistant Director of Nursing (ADON) said if a resident has a fall,

the nurse would go in and do a head to toe assessment on the resident, take VS, do a pain assessment, skin assessment, the nurse would notify the ADON or weekend supervisor of the fall, and also notify the physician and contact the family member listed on the resident's face sheet. A progress note of what was observed and what happened would be completed and the notifications would be listed in the progress note. Neuro checks would be completed for 72 hours if the fall was unwitnessed or if the fall was witnessed with the resident hitting the head. If a fall is unwitnessed, neuro checks are completed even if the resident voices that they did not hit their head. Follow up documentation would be completed for 72 hours after the fall on each shift. That documentation includes neuro checks if indicated, a progress note that would say something like IFU day two out of three post fall, no pain, if the resident had a skin tear from fall, it would say dressing changed, neuro checks WNL. If there are any interventions that are in place, the progress note should also list what the interventions are and that they are in place. The VS can be documented on

the neuro check sheet, in the progress notes or in the VS section of the resident chart. During an interview

on 8/15/25 at 2:39 P.M., the DON said staff know what interventions are in place because every morning

the ADON gives the staff report. The staff would also know by going into a resident's room if they have fall mats next to the bed. All residents should be in a high/low bed and any residents who are a high fall risk should be at the nurse's station when out of bed. The DON expected interventions listed in the care plan to be in place and for the care plan to be accurate and up to date. The DON expected neuro checks to be completed if half a resident's body had fallen off the bed and the resident's head was on the floor under a chair. The DON expected floor mats to be on the floor next to the resident's bed if that is an intervention listed in the resident's care plan. The DON expected progress notes to be completed each shift for 72 hours

after a resident has a fall. During an interview on 8/15/25 at 1:10 P.M., the Administrator and DON said they both expected staff to be knowledgeable of and to follow the facility policies. They both expected resident care plans to be accurate and up to date. They expected the interventions listed in care plan to be in place.

They expected the nursing staff to know where to go in the electronic charting to find interventions for residents. They said the Kardex and care plan is where the interventions can be found. 5. Observation on 8/15/25 at 10:05 A.M., showed the hot water temperatures at the sink fixture, in room [ROOM NUMBER] measured 134.6 degrees F when tested with a digital thermometer for two minutes. Review of Resident #12's medical record, showed no cognitive impairment. 6. Observation on 8/15/25 at 10:43 A.M., showed

the hot water temperatures at the sink fixture, in room [ROOM NUMBER] measured 136. 8 degrees F when tested with a digital thermometer for two minutes. Review of Resident #13's medical record, showed no cognitive impairment. 7. Observation on 8/15/25 at 8:45 A.M., showed the hot water temperatures at the sink fixture, in room [ROOM NUMBER] measured 129.5 degrees F when tested with a digital thermometer for two minutes. 8. During an interview on 8/15/25 at 1:00 P.M., the Maintenance Director said he has had no issues with water temperatures when doing his testing rounds once a week for several months now.

There have been no requisitions for him to fix or adjust any water temperatures from nursing staff or other departments. He was unaware the hot water temperatures were not in range until today. 2581167

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St Sophia Health & Rehabilitation Center

936 Charbonier Road Florissant, MO 63031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited ST SOPHIA HEALTH & REHABILITATION CENTER in FLORISSANT, MO for a deficiency under regulatory tag F-F0698 during a complaint investigation conducted on 2025-08-18.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of ST SOPHIA HEALTH & REHABILITATION CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-24.