St Sophia Health & Rehabilitation Center

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

confusion and elevated respiratory rate. His/Her blood glucose level was 233. 4. Review of Resident #17's quarterly MDS, dated [DATE REDACTED], showed:-Cognitively intact;-Diagnoses of high blood pressure and diabetes mellitus;-Received insulin injections seven out of the last seven days. Review of the resident's care plan, showed:-9/23/25, Focus: Diabetes Mellitus and has orders for insulin. Goal: Will have no complications related to diabetes. Interventions: Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. Review of the resident's POS, showed:-Order Date 9/4/25. Insulin Degludec (long-acting insulin). Inject 22u subcutaneously in the afternoon;-Order Date 9/4/25. Insulin Lispro. Inject 5u subcutaneously before meals;-Order Date 9/4/25: Insulin Lispro. Inject per sliding scale if: 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, 351-400 = 8u before meals for blood glucose control. No order when to notify

the physician. Review of the resident's MAR, dated 9/1/25 through 9/30/25, showed: -Order Date 9/4/25: Insulin Lispro. Inject per sliding scale if: 200-250 = 2u, 251-300 = 4u, 301-350 = 6u, 351-400 = 8u before meals at 7:30 A.M., 11:00 A.M. and 4:00 P.M. for blood glucose control:-9/16, 9/25, 9/26 and 9/27 at 7:30 A.M., no blood glucose levels documented;-9/20 and 9/22, at 11:00 A.M., no blood glucose levels documented;-9/25 at 4:00 P.M., no blood glucose level documented. Review of the resident's progress notes, showed:-9/30/25 at 1:21 P.M.: Resident is (on) leave of absence (LOA) at physician's follow-up appointment;-9/30/25 at 5:24 P.M.: Resident remains at physician's appointment;-9/30/25 at 11:31 P.M.: Charge nurse was notified that resident was admitted to the hospital for hypoglycemia (low blood glucose) and hypotension (low blood pressure) 4. 5. During an interview on 10/2/25 at 12:54 P.M., LPN D said if there are orders to call the physician for a low/high blood glucose level, he/she would contact the physician if a blood glucose level is 60 or below, or above 400. If the physician has ordered parameters of when to be notified and a blood glucose level exceeded those parameters, he/she would contact the physician and document it in the progress notes. Any time he/she documents an NA or HD, he/she would document the reason in the progress notes. The blood glucose levels should be documented on the MAR. 6. During an

interview on 10/2/25 at 1:19 P.M., LPN G said if a sliding scale insulin does not have orders to notify the physician, he/she would contact the physician and ask for orders. When a physician is contacted for a low or high blood glucose level, it should be documented in the progress notes along with any new orders received. Any time insulin is not administered as ordered, the physician should be notified and the reason why it was not given documented in the progress notes. If there were no parameters to call a physician, he/she would call if a blood glucose level was below 60 or above 450. 7. During an interview on 10/3/25 at 2:00 P.M., the DON said she identified a problem in September with staff failing to notify physicians when blood glucose levels exceeded parameters, not consistently documenting blood glucose levels, and documenting NA and NI with no explanation as to why in the progress notes. She provided the inservices, dated 9/19 and 9/22, that showed the following topics were discussed: Blood sugar requirements/protocols, insulin administration, emphasis on requirements for narrative progress notes when glucose is out of range to include physician notification. Apparently, the problem has not been corrected. She expected staff to follow the physicians' orders and notify physicians when blood glucose levels exceeded the ordered parameters. If sliding scale order does not specify when to contact the physician, she expected staff to either follow the facility policy or contact the physician and ask when they want to be notified. When nurses contact the physicians, they should document it in the progress notes. When nurses document NA or NI, there should be an explanation documented in the progress notes. She does not know why this is not being done. 2597610

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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

10/03/2025

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

medical record EMR, showed diagnoses of end stage renal (kidney) disease, muscle weakness and diabetes. Review of the resident's care plan, located in the EMR, showed:-7/18/25, Focus: Activities of daily living deficit. Goal: Will maintain current level of function with ADLs. Intervention: One person assistance with ADLs. During observation and interview on 9/30/25 at 1:17 P.M., the resident (Resident #18's roommate) sat in his/her room in a wheelchair feeding himself/herself lunch. The resident said staff do not offer to brush his/her teeth in the morning. He/She had been at the facility for about two or three months and had not had his/her teeth brushed once. The resident gave permission for the surveyor to check his/her cabinet drawers. No toothbrush, toothpaste or mouthwash was found. During observation and interview on 10/1/25 at 1:18 P.M., CNA H said he/she was assigned to the resident today. He/She did not offer the resident oral care because the night shift was getting the resident up this morning, and all he/she did was assist with the transfer. He/She thought the night shift provided the resident with oral care. The resident said he/she does not and has never had a toothbrush, toothpaste or mouthwash for oral care since being admitted . The CNA looked in the resident's cabinet drawers and could not find a toothbrush, toothpaste or mouthwash. The CNA said he/she always brushes his/her own teeth every morning, and oral care should be offered to the resident's every day. 3. Review of Resident #15's admission MDS dated [DATE REDACTED], showed:-admission date of 8/18/25;-Adequate hearing;-Clear speech - distinct intelligible words;-Makes self understood: Understood;-Ability to understand others: Understands - clear comprehension;-Cognitively intact;-No behavioral symptoms;-Rejection of care: Behavior not exhibited;-Oral hygiene: Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Review of the resident's medical diagnoses located in the EMR, showed diagnoses of diabetes, altered mental status and muscle weakness. Review of the resident's care plan, located in the EMR, showed:-9/4/25, Focus: ADL self-care performance deficit. Goal: Will maintain current level of function with ADLs. Intervention: One person assistance with all ADLs. During observation and interview on 9/30/25 at 7:30 A.M., the resident said he/she has his/her own teeth. Staff do not offer him/her oral care in the morning. He/She would like to have his/her teeth brushed. He/She gave permission to open his/her cabinet drawers. No toothbrush, toothpaste or mouth wash was observed. He/She said no one had given him/her those items since coming to the facility. 4. During an interview on 10/2/25 at 1:10 P.M., CNA E said he/she always brushes his/her own teeth every morning and then uses mouthwash so his/her breath won't smell.

Oral care should be offered to all the residents every day. 5. During an interview on 10/2/25 at 1:12 P.M.

Certified Medication Technician F said he/she brushes his/her own teeth every morning. Oral care should be part of the resident's morning routine every day. 6. During an interview on 10/2/25 at 1:19 P.M., LPN G said he/she brushes his/her teeth every morning, so his/her breath is not bad. Oral care should be offered to the residents every morning. 7. During an interview on 10/2/25 at 1:45 P.M., the DON said she expects staff to provide oral care to each resident every morning. Each resident should have a toothbrush, toothpaste and mouthwash in their rooms. MO2597610

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

10/03/2025

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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

said he/she used to receive restorative services, but he/she has not had any services in a long time. He/she could not recall the last time he/she received restorative services and said he/she would like to get the restorative exercises again. 4. Review of Resident #23's admission MDS, dated [DATE REDACTED], showed:-Cognitively intact;-Able to ambulate 10 feet;-Minimal assist with ADLs; \-Functional Range of Motion- impairment on one side-lower extremity;-Uses a cane or walker. During an interview on 10/1/25 at 1:00 P.M., the resident said he/she used to receive restorative services, and they would come down and walk with him/her two to three times a week. It has been a while since restorative therapy walked with him/her. 5. Review of the restorative aide's binder showed restorative plans developed by therapy for Resident #1, #21, #22, and #23. The plans involved range of motion (ROM) exercises three times a week.

Residents #1, #21, #22 and #23 received restorative therapy services two times within the prior ten days. 6.

Review on 10/3/25 at 11:00 A.M. of the facility's daily staffing sheets, dated 9/23/25 through 10/3/25 showed the restorative aide was pulled to the floor seven out of 12 days. 7. During an interview on 10/1/25 at 7:002A.M., the (Restorative Nurse Assistant) RNA said he/she gets pulled to the floor and there is no one to do restorative. He/She said any CNA (Certified Nurse Assistant) can do range of motion, restorative exercises or stretching, but it doesn't always happen. The Restorative Aide said he/she gets pulled to the floor almost daily. 8. During an interview on 10/2/25 at 12:15 P.M., the Physical Therapist said he/she writes

the restorative plans and orders for each resident who she/he feels is a candidate for restorative based on

the therapy evaluations of all disciplines. Resident #1 was evaluated by therapy and referred to restorative for passive stretching exercises to hopefully prevent contracture. Therapy staff were aware of the restorative not getting done every day, and is aware restorative is not being done as ordered due to staffing issues. 9.

During an interview on 10/3/25 12:00 P.M., the Director of Nursing (DON) said the restorative program needs revamped, started over, from the ground up, and agreed that restorative is not always getting done as it should. 25944212603798

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

10/03/2025

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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

live independently due to his/her mental acuity. Somedays the resident is ok, and somedays he/she is not.

Physically, the resident is independent with his/her ADLs. During an interview on 10/3/25 at 10:11 A.M., SSD J said the resident can express his/her own needs, but it seems to come and go. If he/she had been here longer, he/she would have contacted the resident's physician and/or psychiatrist to determine if the resident should be his/her own responsible party. If yes, there are other resources available that may have been able to help the resident with discharging and residing in the community. When he/she spoke to the resident's family, they said the resident does ok and whatever the facility felt was best for the resident is ok with them, but they do not want to be involved in any decisions. During an interview on 10/3/25 at 12:06 P.M., the Regional Director said discharge planning should begin before admission. A search for a place for

the resident to discharge should have started before August, when SSD I contacted Money Follows the Person. If the resident's cognition was in question, they should have involved the resident's physician to evaluate the resident. If it was determined the resident was not capable of making good sound choices for himself/herself, then they should have contacted the corporate attorney on how to proceed since the resident was admitted as his/her own responsible party and the family did not want to be involved.

Event ID:

Facility ID:

If continuation sheet