St Sophia Health & Rehabilitation Center

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review, the facility failed to ensure medical records containing protected health information (PHI) were not accessible to individuals who do not have the right to view the protected health information, for one resident (Resident #23) when staff provided an after-visit summary for Resident #23 to the family of a different resident. The facility census was 159.Review of the Know Your Rights statement, posted at the front entrance of the facility showed resident rights included confidentiality.

Medical, personal, social or financial affairs should be considered privileged information. During an

interview on 12/31/25 at 1:30 P.M., the family member for Resident #10 said a couple weeks ago on December 17th, the resident's nurse handed him/her the after-visit summary for Resident #23. The family member told the staff person about the mistake, and the staff person told the family member that he/she did not care and did not want the paperwork back and the family member could do whatever he/she wanted to with the documents. The family member still has the after-visit summary for Resident #23's doctor visit that includes the resident's name, date of birth , and follow-up testing that was recommended and he/she would provide a copy to the surveyor. Review of the record provide by Resident #10's family member, showed an after-visit summary dated December (the rest of the date not legible). Only the front page of a multi-page

record was provided. The front page of the record included the resident's full name, medical record number, date of birth , referrals for an MRI of the spine and the pain clinic, and results of an x-tray completed during

the visit. Review of Resident #23's medical record, showed no after-visit summary dated December matching the record sent, available in his/her medical record. During an interview on 12/31/25 at 3:40 P.M.,

the Administrator and Director of Nursing (DON) said only the residents, their guardian, and power of attorney (POA) should have access to a resident's medical record. The Administrator said if staff find out

they accidentally gave someone's medical records to the wrong family member she would expect them to take the paperwork back. Management then must notify the legal team and notify the family. 2697454

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:

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

12/31/2025

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 0584 Level of Harm - Minimal harm or potential for actual harm

cases of 12 plates ordered, to equal 24 plates. During an interview on 12/31/25 at 3:40 P.M., the Administrator and Director of Nursing said residents should be provided with a homelike environment. This includes a homelike dining service. They would expect there to be enough dishes so each resident could eat off real plates instead of Styrofoam.26865782699782

Residents Affected - Few

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

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

12/31/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, when the narcotic count sheet for one resident was lost, resulting in 30 narcotic pain pills with no reconciliation (Resident #12). The census was 159. Review of the Controlled Substance Storage Policy, revised 03/2017, showed:-Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.-Procedures:-The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances.-A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule 11, III, IV, and V medications, including those in the emergency supply. Review of Resident #12 medical record, showed:-Diagnoses included opioid dependence with opioid-induced mood disorder, sleep apnea, and hemiplegia left sided (weakness on one side of the body);-An order dated 9/18/25, for Oxycodone (narcotic pain medication) 20 milligram (mg).

Give 1 tablet by mouth every 6 hours for pain. Review of the resident's December 2025, medication administration record (MAR), showed staff documented the administration of Oxycodone 20 mg:-At 12:00 A.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 6:00 A.M.

on 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 12:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25 ;-At 6:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, and 12/22/25. During an interview on 12/31/25 at 2:15 P.M., the Pharmacy Technician said on 12/15/25, the pharmacy sent the resident's 30-day supply, 120 tablets of Oxycodone 20 mg divided on four cards of 30 tablets each and their records show it was received by the facility on 12/15/25. Review of the resident's Controlled Substance and Narcotic Sheets, on 12/31/25 at 2:30 P.M., showed three of the four sheets with accurate reconciliation of medication given. One Oxycodone 20 mg 30 tablet count sheet unavailable for review with no reconciliation for the tablets administered:-At 12:00 A.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 6:00 A.M. on 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25;-At 12:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25 ;-At 6:00 P.M. on 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, and 12/22/25.During an interview on 12/31/25 at 2:30 P.M., Licensed Practical Nurse (LPN) A said narcotic medications are signed in when they are delivered from the pharmacy. The resident receives four cards of Oxycodone 20 mg. Each card is accounted for on the Controlled Substance Sheet. Reconciliation is completed at the beginning and end of each shift and any discrepancies are reported to the Director of Nursing (DON). LPN A does not recall any recent discrepancies and has not had any residents report not receiving their pain medication. During an

interview on 12/31/25 at 2:40 P.M., the DON said she cannot find that narcotic sheet that is missing. The narcotic sheets should all be accounted for and she expects staff to sign out any controlled medication administered as well document the administration of the medication on the MAR. During an interview on 12/31/25 at 3:40 P.M., the Administrator said there should there be an accurate reconciliation of narcotics.

Event ID:

Facility ID:

If continuation sheet