St Sophia Health & Rehabilitation Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
residents assigned to them, including transfer method. If he/she was not sure of the resident's care and transfer status, he/she would ask the nurse prior to transferring or providing care. Any orders should be followed, including transfer orders. During an interview on 11/6/25 at 11:15 A.M., Licensed Practical Nurse (LPN) A said CNAs received reports and complete a walk-through with the previous shift staff prior to starting their shift. Staff were expected to follow the transfer orders for the resident. Resident #1 was to be transferred using a Hoyer lift at all times. During an interview on 11/6/25 at 12:01 P.M., the interim Director of Nursing (DON) said CNAs received report from previous shift and from their nurse. They were expected to follow the resident's care plan and their Kardex (quick reference tool for a resident's care plan). The CNAs should not transfer the resident without using the Hoyer lift, as ordered, for resident's safety. During
an interview on 11/6/25 at 2:46 P.M., the Administrator and the Regional Director of Operation said they expected the staff to follow the appropriate transfers for all residents as ordered and according to their care plan. 2657487
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
11/06/2025
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-Tag F0839
F 0839
Employ staff that are licensed, certified, or registered in accordance with state laws.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to ensure nursing staff working in the facility were licensed to practice in the state of Missouri, when a Licensed Practical Nurse (LPN) on duty, who obtained their nursing license in a different state was working as a LPN in the facility with no Missouri nurses license.
This had the potential to affect all residents. The census was 170.Review of the facility's current Human Resources (HR) General Position Information, showed graduated practical nurses (GPN, an individual who had graduated from nursing school to work as an LPN but had not yet passed the nursing boards) may only work for maximum of 90 days following graduation date. Review of Nursys Quick Confirm License Verification Report (the national database for nurse licensure verification, discipline, and practice privileges, created and operated by the National Council of State Boards of Nursing), showed LPN D not listed as licensed in the state of Missouri. He/She was only licensed and authorized to practice in Illinois state, with license original issue date of 10/29/25. Review of LPN D's employee file, showed:-A Certificate of Completion in the Practical Nursing Program, program completed on 6/16/25;-LPN D started employment
on 6/25/25 as a full-time LPN-GPN (Graduate Practical Nurse). Review of the facility's staffing schedule dated 10/1/25 through 11/6/25, showed the following dates LPN D was scheduled to work as a GPN or LPN: 10/5 through 10/7, 10/10, 10/14, 10/22, 10/24 through 10/26, 10/29 through 10/31, 11/3 and 11/4/25.
During an interview on 11/5/25 at 3:24 P.M., LPN D said he/she was employed by the facility since June 2025 as a GPN. He/She passed the licensure examination a couple weeks ago and started working as an LPN at the facility right after that. He/She was providing care and administering medications to residents with tracheostomies (a hole surgically recreated in the airway for individuals who cannot breath through the mouth and nose), tube feedings, and administering insulin medications. He/She also provided wound care treatment to his/her assigned residents. He/She was rarely monitored or paired with an experienced nurse.
During an interview on 11/6/25 at 12:01 P.M., the interim Director of Nursing (DON) said GPNs were expected to work with another nurse at all times. There should be oversight from a licensed nurse every day
they work. HR was responsible for checking and reviewing the employees' credentials. The DON expected HR to follow-up the GPN's status. LPN D resigned on 11/5/25, due to the phone call and questions from the state surveyor. During an interview on 11/6/25 at 2:46 P.M., the Administrator and the Regional Director of Operation (RDO) said they were not aware that LPN D was not licensed in Missouri. The Administrator and
the DON both started their employment on 11/3/25 and were not made aware of the situation. They expected the HR staff to make sure all employee credentials were checked and verified. The RDO said HR should track the 90-day mark of the GPNs. GPNs should be precepted or working with another nurse until officially licensed. During an interview on 11/7/25 at 9:55 A.M., Regional HR said he/she was not aware of LPN D's status. The facility had 2 HR personnel prior to him/her taking over the position temporarily. He/She expected the facility HR to verify the applicants background and if they were authorized to work in the state.
He/She expected the facility HR to collect the school's transcript records, copy of the NCLEX (National Council Licensure Examination) registration and authorization to test with the date of testing. A GPN can work until licensed or for 90 days after graduation, whichever comes first. 2657062
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
ST SOPHIA 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 ST SOPHIA HEALTH & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.