St Sophia Health & Rehabilitation Center
ST SOPHIA HEALTH & REHABILITATION CENTER in FLORISSANT, MO — inspection on December 31, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
265120 12/31/2025
St Sophia Health & Rehabilitation Center 936 Charbonier Road Florissant, MO 63031
During an interview on 12/30/25 At 1:40 P.N., the resident said the food is terrible. He/She is not sure what is going on in the kitchen.
The facility needs more money to spend on dietary.
Observation at 1:57 P.M., showed staff brought lunch to the resident on a Styrofoam plate.
Staff served a taco, refried beans, and corn.
The plate was wrapped in plastic wrap.
The resident touched it and said it is cold and the taco shell is soggy from being wrapped in plastic. He cannot eat that stuff.
Staff always serve their food on Styrofoam, unless residents eat in the main dining room.
Staff have been serving food this way for months. He/She does not like Styrofoam, he/she is not a kid.
Plus, plates would help keep the food warm and would be easier to eat off of.
Observation on 12/31/25 At 9:07 A.M., in the main dining room, showed meal service in progress, staff serve meals from the steam table on Styrofoam plates, wrap them in plastic, and placed them on carts to be sent to the halls.
The Dietary Manager (DM) said they are using Styrofoam plates because they ran out of regular plates, that is what they must do.
They do not have enough plates.
Observation on 12/31/25 at 12:06 P.M., showed dietary staff prepped lunch and set up the steam table.
Tour of the kitchen and dining room service station showed approximately 60 plates available and a large stack of Styrofoam plates. No dirty plates were in the dish washing area in the kitchen or other plates in storage. At 12:13 P.M., a dietary aide (DA) who stood at the steam table and served food said this is all the plates they have.
They order them and then they go missing.
It has been about 2 months since more plates were ordered, and they are already gone.
Staff serve on regular plates until they run out.
Observation at this time showed dietary staff serving food to residents in the main dining room on regular plates. At 12:34 P.M., all residents in the main dining room were served lunch.
Dietary staff began to serve trays for the 100-hall.
The DM came in and asked one of the dietary staff to search the hall for plates. At 12:38 P.M., approximately halfway through the 100-hall cart, dietary staff ran out of plates and switched to Styrofoam. At 12:45 P.M., a dietary staff person who had left to search for plates returned from the halls with 4 regular plates and one divided plate. He/She took them to the dishwasher. At 12:48 P.M., staff finished the 100 hall trays and started to serve the 200-hall trays on Styrofoam. At 12:58 P.M., the plates that were washed were placed on the back serving station.
Dietary staff prepared the 300 and 400 hall trays.
The four regular plates that were located and washed were used for the 300/400-hall cart, then the rest of the meals were served on Styrofoam.
During an interview on 12/31/25 at 2:25 P.M., the Administrator provided an invoice for plates that were ordered recently and said she is looking for the prior order because she just started in November and cannot locate the last time plates were ordered by the prior administrator.
Review of the invoice, dated 12/30/25, showed two 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
265120 12/31/2025
St Sophia Health & Rehabilitation Center 936 Charbonier Road Florissant, MO 63031
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.